LINE OF DUTY (LOD) PROGRAM

DESKTOP GUIDE Revision Date: 8 March 2011

IMPORTANT

The policies and procedures set forth in this guide are not retroactive. Any policy or program changes can be found at http://www.npc.navy.mil/CareerInfo/ReservePersonnelManagement/MedicalYou should routinely check this website for updates. Additionally, all points of contact (POC) are provided for your convenience. Do not release any phone numbers contained in this desktop guide without authorization from the appropriate POC.

PREFACE About this desktop guide:

This desktop guide was created to help give you a better understanding of the Line of Duty (LOD) Program, formerly referred to as the Notice of Eligibility (NOE) Program. This program provides benefits for Reserve Component (RC) members who incur or aggravate injuries, illnesses or diseases while in a duty status. Without the LOD, the Reserve Component (RC) member is not entitled to any benefits. Benefits may include medical or dental care and/or incapacitation pay depending on individual circumstances. Whether you are a Seaman Recruit or a Master Chief Petty Officer, it is imperative that you understand this program so that you may advise your Sailors and your Commanding Officer (CO) appropriately. Both the Sailor and the CO count on you becoming a subject matter expert concerning the LOD program. The Sailor needs you to explain his or her rights and responsibilities, and the CO needs viable input from you to make informed decisions. The amount of effort that you put forth in understanding this program is directly proportionate to the success of the program. Remember, both your actions and inactions affect the Sailor’s quality of life. As such, the Sailor must be your priority. MISSION FIRST...SAILORS ALWAYS! LOD Points of Contact Address: Commander, Navy Personnel Command (PERS-95) Bldg 768, Room N115 5722 Integrity Drive Millington, TN 38054-0000 Fax: (901) 874-2689 Email: lod@navy.mil LOD Program Supervisor: Comm: (901) 874-4229 DSN: 882-4229 Reserve Component Command (RCC) Northwest Program Manager: Comm: (901) 874-4257 DSN: 882-4257 Reserve Component Command (RCC) Southwest Program Manager: Comm: (901) 874-4245 DSN: 882-4245

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Reserve Component Command (RCC) Southeast Program Manager: Comm: (901) 874-4236 DSN: 882-4236 Reserve Component Command (RCC) Midwest Program Manager: Comm: (901) 874-4239 DSN: 882-4239 Reserve Component Command (RCC) Mid-Atlantic Program Manager: Comm: (901) 874-4244 DSN: 882-4244

TABLE OF CONTENTS Chapter 1. Submitting a Line of Duty (LOD) Request............... 2 References............................................ 2 Definitions........................................... 2 Required Forms........................................ 3 Procedures for preparing a LOD request................ 4 2. Appealing to the Office of the Judge Advocate General. 12 References............................................ 14 Background............................................ 14 Procedures for preparing an appeal.................... 14 3. Managing a LOD case................................... 14 Creating a case file.................................. 17 Reviewing the plan of care............................ 18 Reviewing Medical Documentation....................... 18 Modifications Extensions Closures Reinstatements Waivers for orders 4. Requesting Pay........................................ 23 References............................................ 23 Definitions........................................... 23 Required forms........................................ 24 Procedures for requesting pay......................... 25 5. Obtaining Pre-Authorization for Care and Processing

Claims................................................ 27 References............................................ 27 Required forms........................................ 27 Procedures for obtaining pre-authorization............ 27 Procedures for processing claims...................... 29 6. Disability Evaluation System.......................... 31 References............................................ 31 Background............................................ 31 Procedures for initiating a Medical Evaluation Board.. 31 7. MRR Physical Evaluation Board (PEB) Packages.......... 36 References............................................ 36 Background............................................ 36 Required forms........................................ 36 Processing a PEB package.............................. 37

TABLE OF CONTENTS Enclosures 1. Refusal of LOD benefits, NAVPERS Form 1070/613 2. Command letter requesting a LOD 3. Copy of LOD Privacy Act Statement 4. Line of Duty Investigation (DD Form 261) 5. Authorization for Disclosure of Medical or Dental Information

(DD Form 2870) 6. Member’s Privileges and Responsibilities for LOD Medical Care

and Incapacitation Pay Benefits, NAVPERS Form 1070/613 7. Reporting of Civilian Earned Income or Loss of Earned Income

for Incapacitation Pay Benefits, NAVPERS Form 1070/613 8. Appeal Letter 9. Physician Recommendation/Limitation for Civilian Employment

and Military Duty (PR) 10. LOD Modification Request Format 11. LOD Change Request Format 12. LOD Closure Request Format 13. LOD Incapacitation Pay Request 14. LOD Extension Request Format 15. LOD Reinstatement Request Format 16. Reserve Component Medical Eligibility Verification 17. Reserve Component Pre-Authorization Request for Medical Care 18. Pre-Authorization Request for Dental Care 19. MMSO Appeal 20. MMSO Dental Information Sheet 21. Prescriptions that require a prior authorization 22. Prescriptions that have a quantity limit 23. Consultation Sheet, SF-513 (Navy) 24. Non-Medical Assessment (NMA) 25. Severance/TDRL/PDRL 26. Member letter requesting PEB 27. LOD Understanding Appendix A. LOD Checklist......................................... A1 B. Standard Form 600 Entry Required for LOD Refusals..... B1 C. Incapacitation Checklist.............................. C1 D. PEB Checklist..................................... D1 E. Points of Contact....................................... E1 F. MMSO Points of Contact.................................. F1

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Chapter1: Submitting a Line of Duty (LOD) Request Ref: (a) SECNAVINST 1770.3D (b) DOD Directive 1241.2 of 30 May 01 (c) SECNAVINST 1850.4E (d) Title 10 USC, 1074a (e) SECNAVINST 5216.5D (f) MANMED, Chapter 18 (g) BUPERSINST 1001.39F (h) Title 37 USC, 204(g), (h) and (i) (i) MILPERSMAN 1050-180 I. Purpose

A. To assist you in the preparation of a LOD request. Per reference (a), Deputy Chief of Naval Operations (Manpower, Personnel, Training, & Education) is the Benefits Issuance Authority (BIA) for Line of Duty (LOD) benefits. Commander, Navy Personnel Command (PERS-952) manages the LOD program for the DCNO. PERS-952 will review the LOD request and determine whether the member’s medical condition was incurred or aggravated during a duty status.

B. Quick identification of a member’s eligibility for LOD benefits will enable the medical care of the member to be handled under the LOD program.

C. Transitional Assistance Management Program (TAMP) benefits should not be used in place of LOD benefits to care for Navy Reserve service connected medical conditions. II. Definitions

A. Incurred. To occur as a result of or during military duty per reference (b). Incurred refers to the date or time when an injury, illness, or disease is contracted or suffered, as distinguished from a later date when it is determined that, because of such injury, illness, or disease a member has become unfit to perform his/her duties per reference (c).

B. Aggravated. The worsening of a pre-existing medical condition over and above the natural progression of the condition as a direct result of, or during military duty per reference (b). An increase in physical impairment during service in excess of the natural progression of an injury, illness or disease is considered aggravated by service per reference (c).

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C. Duty Status. Any period of active duty, funeral honors

duty, or inactive duty training. While traveling directly to or from the place of duty. While remaining overnight immediately before the commencement of inactive duty training or between successive periods of inactive duty training. At or in the vicinity of the site of the inactive duty training, if the site is outside reasonable commuting distance of the member’s residence. While remaining overnight at or in the vicinity of the place the funeral honors duty is to be performed immediately before serving such duty, if the place is outside of reasonable commuting distance from the member’s residence.

1) Reserve terminology for types of duty status: Inactive Duty Training (IDT), Annual Training (AT), Active Duty for Training (ADT), Inactive Duty Training Travel (IDTT), Initial Active Duty Training (IADT) (i.e. basic training), Active Duty for Special Work (ADSW), and Recall to Active Duty (i.e. presidential recall, mobilization) per references (b) and (d).

D. Manifestation. The revealing of an underlying or pre-existing condition that was not aggravated during a duty period.

E. Line of Duty (LOD). A document authorizing benefits for a service member whose duty status and conduct at the time of such injury, illness or disease was incurred or aggravated while in the line of duty. III. Required Forms. A checklist is provided in Appendix A.

A. Command letter requesting a LOD B. Copy of LOD Privacy Act Statement C. Copy of Orders / DD214 / Drill muster sheet at the time

of incident D. Copy of all available medical documentation from the

time of incident (civilian, military, ER reports) E. Copy of Motor Vehicle Accident Report (if available) F. Copy of chronological medical care pertaining to injury,

illness or diagnosis (if applicable) G. Copy of physical exams, PHA, Dental (T-2) exam, Pre-Mob

& Post Mob assessment(as applicable) H. Statement from witnesses (if applicable) I. Line of Duty Investigation (DD form 261) J. Copy of Physical Fitness Assessment (PFA) screening /

PFA & BCA result (if applicable)

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K. Authorization for Disclosure of Medical or Dental Information (DD form 2870)

IV. Procedures for preparing a LOD request

A. Counsel the member about the LOD process. Do not make any promises concerning approval of benefits. If the member refuses LOD benefits, have him/her sign the Page 13 Refusal of LOD Benefits, enclosure (1) and make an entry in the member’s health record as shown in Appendix B. Ensure that the page 13 is placed in the member’s service record. **Note** Refusing LOD benefits does not erase the fact that the member has a medical condition and may not be Fit for Duty. Member should be placed TNPQ or a Medical Retention Package submitted.

B. Enter the LOD request in Medical Readiness Reporting System (MRRS). If you do not have access, contact your MRRS security manager.

1. Open MRRS.

2. Move the mouse over “Injury Management” menu.

3. Move the mouse over “Reserve Component”.

4. Move the mouse over “LOD”.

5. Click “LOD Entry”

6. Enter the last four of the member’s social security number and click “Apply”.

7. Open the record that you want to edit.

8. Click on the “Request” tab and fill in all required fields (marked with a red asterisk).

a) For the “Date of injury” block, select the date the member incurred or aggravated the condition. If member cannot specify a date (such as for a PDHRA), pick a date. Make every attempt to locate medical documentation for the condition close to this date. **Note** Date must be within the period of duty noted in the “Order Dates” block.

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b) For the “Injury Code” block, select the appropriate code. If you are submitting an LOD request because of a PDHRA, select PDHRA.

c) For the “Injury Category” block, select the appropriate category. If the member has multiple conditions, select “Miscellaneous” then list each condition in the “Injury/Illness” block.

9. Click on the “MDR” tab and fill in your contact information.

10. Press “Save”. A text box will appear and ask whether you want to print the forms.

11. Select “OK”. A separate web browser will open. If a security information box appears, select “Yes” and print forms.

12. If the member refuses LOD benefits you must still open the LOD case in MRRS.

a) Print the Page 13 “Refusal of LOD Benefits” from this desktop guide.

b) Have member state the conditions that they are refusing LOD benefits for and enter them on the form.

c) Have member sign the Page 13.

d) Email or fax the Page 13 to the LOD shop. The LOD shop will close the MRRS entry and include it in the member’s archived file.

C. Prepare the forms.

1. Command letter requesting a LOD (enclosure (2)). Detailed explanations of circumstances are required. Ensure that the details are added after the colon punctuation in each line. Attention-to-detail is a must when completing, but not limited to, the following paragraphs:

a) Paragraph 1c, provide the type of orders and the period of the orders.

b) Paragraph 1d, provide the date, place, and circumstances of injury, illness or disease. Be specific.

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c) Paragraph 1e, provide a diagnosis. If a diagnosis has not been established, generalize the injury, illness, or disease.

d) Paragraph 1f, indicate whether the member was/is hospitalized. Per ref (b) and (d), if the member is currently hospitalized, ensure that the member remains in a duty status for the duration of hospitalization. Examples: (1) if the member is currently on AT/ADT orders, the orders should be extended until released from the hospital. (2) If the member was hospitalized during an IDT period, your command must ensure he/she remains under a duty status (i.e. assign IDT for days hospitalized or issue AT/ADT orders) until the member is released from the hospital. These orders should be coordinated via the members reserve chain of command for approval and funding. Submit hospital bills to MMSO for payment.

e) Paragraph 1g, make a determination if the injury occurred “In the Line of Duty” or “Not in the Line of Duty”. If the command cannot make an accurate determination if the condition was incurred or aggravated during the duty status, DO NOT state a determination. Instead make a statement explaining the command finding.

f) Paragraph 1m, provide an explanation if the LOD request is submitted greater than 10 days after the injury.

1) The intent of this paragraph is to establish

whether the member informed you of his/her injury within a reasonable time after the injury as per reference (a).

2) To ensure timely approval of LOD benefits, it is critical that LOD requests are submitted immediately after the injury.

3) If the LOD request is submitted greater than 10 days, a brief explanation is warranted (ex. Delay in submission due to member not reporting injury / illness because they thought the pain would go away; or Delay in submission due to member and command gathering pertinent documents).

g) Paragraph 1n, make a recommendation for the type of LOD (Drilling or Non-drilling) that you are requesting.

1) Request for Non-drilling LOD must be supported by medical documentation from the treating physician

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stating that the member’s injury or illness prevents him from performing any type of duty during a drill weekend.

2) If a member’s injury or illness prevents him from performing his normal military job, but still enables him to perform some type of job in a light or limited capacity a Drilling LOD is the appropriate recommendation. Example, an EO2’s knee pain prevents him from operating heavy machinery, but can perform some administrative job during the drill weekend.

3) Providing explanation supporting for CO’s

recommendation will assist PERS-952 in the final determination of benefits. The Drilling or Non-drilling status can be modified by PERS-952 based on physician recommendations on changes in the member’s condition once the LOD is approved.

2. LOD Privacy Act Statement, enclosure (3). Ensure that both the member and a witness sign and date this form. The witness signature is not attesting to the facts of the statement but rather to the fact that the member signed the form. The MDR may sign as the witness.

3. Copy of Orders/IDT Participation Record pertaining to the time of incident. For orders greater than 30 days, a copy of the DD214 should be forwarded. However, a copy of mobilization and demobilization orders may be forwarded if the DD214 is not available. The DD214 will be required if the injury occurred while the member was in a terminal leave status.

4. Copy of all available medical documentation from the time of incident (civilian, military, ER reports). Make sure that it coincides with the duty period. It is pertinent that medical documentation from the time of injury or illness is provided. Failure to provide medical documentation will not necessarily lead to denial of LOD benefits; it just makes it more difficult to prove the injury was incurred during the duty period.

5. Copy of Motor Vehicle Accident (MVA) Report (if available). This must be provided as soon as possible. Any requests greater than 30 days of the incident must include the MVA report. Per references (b) and (d), if the report and DD261 reveal that the member operated the vehicle under the influence and due to misconduct, the LOD request will be denied.

6. Copy of chronological medical care pertaining to injury, illness or diagnosis (if applicable; civilian or

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military). This information should be forwarded if the member sought treatment after the end of the duty period.

7. Copy of last physical and PHA. If mobilized and deployed, copy of Pre-deployment and Post-deployment PHAs.

8. Statement from witnesses (if applicable). This is required if medical documentation relating to time of incident is not available. A statement from an eyewitness is preferred; however, a statement from a senior person is acceptable. Utilize enclosure (3) when obtaining a witness statement. Ensure that both the eyewitness and a witness sign and date this form. The witness signature is not attesting to the facts of the statement but rather to the fact that the member made a statement.

9. Report of Investigation (DD form 261), enclosure (4). Type in all information. Attention-to-detail is a must when completing, but not limited to, the following blocks:

a) Block 1. Enter the date that you completed this

form.

b) Block 2. Indicate whether the medical condition is an injury, illness, or disease.

c) Block 3. Select one choice pertaining to type of orders (3a, 3b, 3c, or 3d). You must fill in 3e if the member was on IDT or ADT orders.

d) Block 4. Address to Commander, Navy Personnel Command (PERS-95).

e) Block 10. Indicate the time, date, and location of the current injury or aggravation. If the medical condition is an illness or disease, the date and location refers to the date of diagnosis and the facility location; the time is not applicable. If the member was in an unauthorized absence (UA) status or misconduct was proven, the LOD request will be denied.

f) Block 11. Mark the block with the appropriate finding. Examples: (1) In Line of Duty; (2) Not in Line of Duty – Not due to own misconduct; (3) Not in Line of Duty – Due to own misconduct. If the command cannot make an accurate determination if the condition was incurred or aggravated during the duty status, DO NOT mark a finding. Instead make a statement in the note section of page 2 explaining the command finding.

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g) Block 12. Make sure that the investigating

officer signs. In most cases, the MDR may be the investigating officer.

h) Block 13. Make sure that the CO signs this block. This block may be signed “By direction” however, the investigating officer cannot sign this block. Ensure that the CO marks either “Approved” or “Disapproved” the investigating officer’s findings.

10. Copy of PFA risk assessment questioner and/or PFA result (if applicable). This is required especially if an injury, illness, or disease was incurred or aggravated while conducting a PFA.

11. Authorization for Disclosure of Medical or Dental Information (DD form 2870), enclosure (5). This form must be completed for each facility where the member sought or intends to seek treatment. Attention-to-detail is a must when completing, but not limited to, the following blocks:

a) Block 4. From the date of injury or illness to one year after signature.

b) Block 5. Select the “BOTH” box. c) Block 6. Enter the name of the treating

facility or physician. If blocks 6a-d are not already completed, fill in the following information:

(1) 6a. “Commander, Navy Personnel Command (PERS-952)”.

(2) 6b. “Bldg 768, Room 115, 5720 Integrity

Drive, Millington, TN 38055-0000”. (3) 6c. “(901) 874-4229”. (4) 6d. “(901) 874-2689”.

d) Block 7. Select “CONTINUED MEDICAL CARE” box. e) Block 8. Enter “All documentation including,

but not limited to, lab and x-ray results”.

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D. Present the LOD request for signature to your Commanding Officer. The LOD request may be signed “By direction”.

E. Scan the LOD request in the following order from first to last document:

1. NOSC Request Letter 2. LODI & Witness statements 3. NAVPERS 1070/613s including LOD Privacy Act,

Privileges & Responsibility, and Civilian Income. Page 2 4. Orders/DD form 214/Drill Muster Sheet/MVA report 5. Disclosure (DD-2870) 6. Physical/PHA/PRIMS/DD form 2697/DD form 2695/DD form

2696/DD form 2900 7. Chronological Medical Care – Most recent note on top.

F. Verify the scanned file is legible and email the package to: lod@navy.mil. If you are unable to scan the document for submission please contact your Reserve Component Command (RCC) Medical for support.

G. Follow-up. Do not call to verify receipt of a package

immediately after sending the LOD request.

1) Your program manager will input a status in MRRS within 3 business days. If you do not see a current status, call your LOD program manager at that time.

2) Generally, the LOD request is processed within 7 calendar days. Check the status update tab in MRRS prior to contacting your LOD program manager for the status of the request.

3) If more information is requested by the program manager, you must submit the requested information as quickly as possible. If the requested information is not received by the program manager within 7 calendar days, the LOD Program Supervisor will contact the command senior enlisted for action. If nothing received in 7 additional calendar days contact will be made with the command CO. The LOD request will be on hold

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until the requested information is received and the program manager will document the reason for the delay in routing the LOD request. After 30 calendar days, the request may be returned without action for missing documentation.

H. Receipt of PERS-952 decision. Ensure that you read each letter in its entirety and endorse it per reference (e) to the member. The following are decisions that can rendered:

1. There are two types of LOD approvals:

a) “Drilling LOD” - the member is able to perform a reasonable amount of his/her military duty with the LOD injury, illness, or disease. This is similar to being in a light or limited duty status. The member may perform IDT and IDTT; however, the NOSC Commanding Officer will ultimately decide if the member will perform IDT or IDTT. It is recommended that the member perform IDT or IDTT as often as their condition allows without further aggravation. This will allows consistent contact with the member for LOD updates. The member may not perform IDT during convalescent periods (after surgery). Per reference (i), convalescent period may be granted for a period of up to 30 days. A Drilling LOD does not authorize the member to go on AT or ADT without a waiver from CNPC (PERS-952). Schedule an appointment with the member and counsel him/her regarding the following documents within 10 days of approval. You may initiate a pay request during this counseling, if applicable. Refer to chapter 4.

1) Member’s Privileges and Responsibilities for LOD Medical Care and Incapacitation Pay Benefits (Page 13), enclosure (6).

2) Reporting of Civilian Earned Income or Loss of Earned Income for Incapacitation Pay Benefits (Page 13), enclosure (7).

3) A medical plan of care from the member’s Primary Care Manager (PCM). An updated medical plan of care must be provided each time it is modified. Refer to chapter 5 for procedures in obtaining a plan of care.

b) “Non-drilling LOD” - the member is unable to perform a reasonable amount of his/her military duty. The member may not perform IDT or IDTT and may not go on AT or ADT (except for the purpose of attending a Medical Evaluation Board). Documentation from the treating physician is required

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to justify a recommendation of a Non-Drilling LOD. Schedule an appointment with the member and counsel him or her regarding the documents previously discussed within 10 days of approval. You may initiate a pay request during this counseling, if applicable. Refer to chapter 4.

2. “Acknowledged” - this means that the member incurred or aggravated an injury, illness, or disease and is entitled to LOD benefits. However, the member was found Fit for Duty (FFD) prior to submission of the LOD request or before an LOD approval was rendered. The Acknowledged LOD letter can be used to document the member’s injury, illness, or disease was Navy Reserve service connected.

a) The Acknowledged LOD can be used to pay for any outstanding civilian medical bills. Only medical bills incurred on or before the “return to duty status” date will be honored. Refer to chapter 5 for additional guidance. Ensure that you inform the member that no further treatment is authorized.

b) Per reference (d) and (h), the member is also entitled for reimbursement of lost wages from the time of incident until the time member was found fit for duty.

3. “One-Time Medical Office Visit (OTV)” – This is issued when CNPC (PERS-952) cannot make a clear determination if the member needs continued medical treatment. The OTV enables the member to receive an evaluation from a primary care or specialty physician to determine if further treatment is required. An OTV is also issued for PDHRA related LOD requests.

(a) Since PDHRA’s are conducted 6 to 12 months post mobilization, member’s stated condition may/may not have been incurred or aggravated during the duty period. The OTV is used to determine the extent of the medical condition.

(b) An entire LOD request package is not required initially. Submit the PDHRA (DD 2900) along with the LOD request letter.

(c) After the member has been evaluated, submit the medical notes to the LOD shop. The LOD shop will then determine if the condition requires an open LOD case, acknowledged, or denied. Additional administrative/medical documentation may be requested by the LOD shop at this time.

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4. “LOD Denied” – this means there was insufficient documentation or the documentation cannot prove that the injury, illness, or disease was incurred or aggravated while in a duty status.

a) If the member still feels that the injury, illness, or disease was incurred or aggravated while in a duty status, the member may appeal. Have the member submit in writing his or her request to appeal the denial to OJAG (refer to chapter 2 for guidance).

5. “LOD Returned” - this means that the LOD request was returned without an LOD determination. Examples of circumstances in which an LOD request will be returned: (1) The LOD request was submitted erroneously; (2) Member was separated for administrative reasons before an LOD determination was made. A MRRS entry will be made by the LOD program manager to explain the reason for the return.

I. “LOD Denied” or “LOD Returned” does not negate the fact that a medical condition exists. The member should be placed Temporarily Not Physically Qualified (TNPQ), if applicable. If the medical condition does not resolve and may limit the member’s readiness, a Medical Retention Review (MRR) per reference (g) should be submitted.

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Chapter 2: Appealing to the Office of the Judge Advocate General (OJAG)

Ref: (a) SECNAVINST 1770.3D (b) DOD Directive 1241.2 of 30 May 01

(c) SECNAVINST 5216.5D I. Purpose. To assist both the MDR and member in the preparation of an appeal to Office of the Judge Advocate General (OJAG). The NOSC Commanding Officer (CO) endorses the appeal to Office of the Judge Advocate General (OJAG) via Commander Navy Personnel Command (CNPC). Per reference (a), CNPC will review the appeal and determine if the member has supplied any additional medical documentation that may aid in overturning the initial denial. If CNPC maintains its previous decision, the package is forwarded to OJAG for a final determination. II. Background. Per reference (a), when a Reserve Component (RC) member is denied LOD benefits, he or she has the right to appeal to OJAG. The member has 60 days to appeal the denial. The member must submit additional information that was not included with the original LOD request. This information should preclude that the denial is unfounded. The appeal is addressed to OJAG (Code 13) via the NOSC CO and CNPC. **Note** A LOD Returned without action is not a denial. There is no need to appeal. The member and NOSC should simply resubmit the package with the missing documentation. III. Procedures for preparing an appeal.

A. Set up an appointment with the member to go over the appeal package. Determine what he or she is contesting and what additional information he or she should submit.

B. Assist the member in the preparation of the appeal letter. A sample appeal letter is provided in enclosure (8).

C. Provide the member with a copy of the LOD request package and the denial letter.

D. Prepare an endorsement per reference (b), stating a recommendation for approval/disapproval. You may need to add a counter-statement to the endorsement if the member claims mismanagement by you or a previous MDR. State the facts only.

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E. Present the endorsement for signature to your NOSC Commanding Officer. The endorsement may be signed “By direction”.

F. Scan the appeal letter, Command’s endorsement letter, additional documents (if applicable) and the entire LOD request in order as in the previous chapter (if applicable) and e-mail to the LOD shop (PERS-952) at lod@navy.mil.

G. Follow-up. Do not call to verify receipt of a package immediately after faxing the appeal. Check the status section in MRRS, the program manager will make an entry when the package has been received. If you do not see a status within 5 working days, call your LOD program manager at that time. Generally, an appeal is forwarded to OJAG, if necessary, within 14 workdays. If CNPC overturns the original decision, refer to chapter 1 and chapter 3 for guidance. Once the package has been forwarded to OJAG, the average response time is three months.

H. Receipt of the OJAG determination. Ensure that you read the letter in its entirety and endorse it per reference (b) to the member. There are two determinations that OJAG makes:

1. “Concur with CNPC, not eligible for LOD benefits”. The member’s appeal process is complete. Place the member in a TNPQ or MRR status for stated medical condition if not previously completed.

2. “Overturn CNPC, eligible of LOD benefits”. PERS-952 issues a LOD and the member’s appeal process is complete. Refer to chapter 1 and chapter 3 for additional guidance.

I. If member still does not agree with the denial after OJAG has made their determination, the member may appeal to the Board for Correction of Naval Records (BCNR). However, the member’s LOD denial stands until the BCNR has made their decision (this process can take up to 2 years). If the BCNR rules in the member’s favor, they can direct CNPC to open an LOD.

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Chapter 3: Managing a LOD Case

I. Purpose. To assist you in managing the medical/dental care and incapacitation pay of your Sailor. This chapter includes case file maintenance, extension requests, modification requests, change requests, and waiver requests. A Reserve Component (RC) member approved for LOD medical and pay benefits will remain entitled to the benefits until they have been found Fit for Duty (FFD), their case has been processed through the Disability Evaluation System (DES), or their case has been closed due to administrative reasons. Because each case is tailored to the individual, you must be engaged in case management from beginning to end. Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual’s health and financial needs. II. Definitions.

A. Modification request. A request to add an additional diagnosis to a current LOD.

B. Change request. A request to change LOD benefits to either a Non-drilling (member is entitled to Full Pay and Allowances) or Drilling (member is entitled to reimbursement of lost civilian wages) LOD.

C. Extension request. A request to extend medical/dental benefits.

D. Reinstatement request. A request to reopen a previous LOD case that was closed or acknowledged. The member must provide all pertinent documentation/statements to justify request.

E. Medical documentation. Documentation of care provided by a physician, family nurse practitioner, or physician assistant. Documentation should, at a minimum, include a diagnosis, prognosis, treatment plan, and limitations. III. Required Forms.

A. Physician Recommendation/Limitation for Civilian Employment and Military Duty

B. LOD Modification Request Format C. LOD Change Request Format

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D. LOD Closure Request Format E. LOD Monthly Update/Incapacitation Pay Request F. LOD Extension Request Format G. LOD Reinstatement Request Format

IV. Procedures for managing a LOD case.

A. Create a case file. To do so, obtain a six-part folder and place the member’s identification information on the folder. Label sections I – VI as follow:

1. Section I – Request and Notes. 2. Section II – LOD Letters. 3. Section III – MMSO. 4. Section IV – Medical Documentation and Pay. 5. Section V – Command Letters. 6. Section VI – DES Information.

B. File documents appropriately.

1. Section I. File the LOD request in this section and

add your notes on top of this section. You should document all communication efforts that you have regarding the case, to include phone calls and emails.

2. Section II. File all correspondence received from Commander, Navy Personnel Command (PERS-952) in chronological order, meaning the most recent letter is on top.

3. Section III. Maintain all MMSO pre-authorizations and medical bills in this section according to date of service in chronological order.

4. Section IV. File all plans of care, medical documentation and pay requests in this section. Ensure that you maintain the facsimile transmittal sheet or email confirmation in this section, if applicable. The plan of care is always on top.

5. Section V. File all correspondence that you initiate regarding the case. This includes extension requests, modification requests, change requests, reinstatement requests, and letters of noncompliance.

6. Section VI. File the findings of the Physical Evaluation Board, Medical Evaluation Board dictation, and SF 513 initiating the medical board in this section.

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C. Review the plan of care. This will give you a general

idea of the frequency of the visits and the type of treatment the member will receive. This information is helpful in knowing when to initiate a LOD extension or medical board (as applicable). Personnel outside the Military Treatment Facility (MTF) catchment area may obtain civilian care. Make sure that pre-authorization has been obtained for any upcoming appointments from Military Medical Support Office (MMSO) (if applicable). Refer to chapter 5 for guidance.

D. Forward a Physician Recommendation/Limitation for Civilian Employment and Military Duty (PR), enclosure (9), to the member at the beginning of the month.

1. Print a new PR form from the LOD Desktop Guide for each occasion of update. Forward this form to the member to ensure that they have it before their next doctor visit.

2. Upon receipt, review the PR or medical documentation.

a) Make sure that the “From” block is completed. This is the information that is needed if you or the LOD shop needs to contact the physician directly.

b) Verify that the member’s name and injury are listed.

c) Verify that the member’s position and responsibilities are listed. Compare the member’s position to his/her limitations to make sure that the member’s injury prevents him or her from performing his/her civilian job if the member is unable to work. Example: Question why a sprained ankle cannot perform clerical and secretarial duties.

d) Review document to see if the member had surgery recently. On some medical documents, the date of surgery is indicated as “DOS”. In addition, the word “post-op” is an indicator that the member had surgery. If this is the case, request a copy of the operative note.

1) Per reference (i), the member is entitled to a maximum of 30 days of convalescent leave. Ensure the member does not drill during his or her convalescent period.

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2) A change request does not have to be submitted for convalescent periods. The LOD program manager will not change the benefits in the system. The member will be paid Full Pay and Allowances once the program manager receives the incapacitation pay request form for the period of convalescent leave (if requested by the member).

e) Make sure that the medical documentation is related the member’s LOD condition. If the member is being evaluated for any condition other than what is authorized, consult with the member and gather all pertinent documentation regarding the new condition.

1) Explain to the member that they may be liable for any medical costs related to treatment received for the condition not covered by the LOD.

2) If the member claims that it is service related, investigate the new condition. If you deem that it is Navy Reserve service related, submit a LOD modification request, enclosure (10).

f) If the member has a “Non-drilling” LOD and was returned to a light duty status, submit a LOD change request, enclosure (11), to change to a “Drilling” LOD. If the member has a “Drilling” LOD and his condition has changed to the point that the physician determines the member should not perform any military duties, submit a LOD change request, enclosure (11), to change to a “Non-Drilling” LOD.

g) If the member has a “Drilling” LOD and was found “Unfit” by the Physical Evaluation Board, submit the PEB findings to the LOD shop. You do not have to submit a LOD change request, enclosure (11), to change to a “Non-drilling” LOD. The LOD shop will automatically note the member’s PEB findings of “Unfit” upon verification of the ENBLOC number.

h) Make sure that member’s care matches the timeline provided in the plan of care. If it does not, contact the member for information.

i) If Occupational Therapy (OT) or Physical Therapy (PT) is additionally treating the member, obtain those notes as well. Remember, a monthly medical update is still required from the member’s PCM along with the PT or OT notes.

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j) Make sure that a physician, family nurse practitioner, or PA signs and dates it.

k) If a military physician states that member is Fit for Duty (FFD) or Fit for Full Duty (FFFD), a members request for closure is not required. Contact the member to inform them that a LOD determination for closure is being forwarded to PERS-952 for review, scan the document and submit it to PERS-952 at lod@navy.mil. If all documentation is in order, per reference (a) the Benefits Issuing Authority will close the case. If a civilian physician states that a member may return to work without restrictions, have a military physician evaluate the note and a determination of FFD or FFFD is required. Although the civilian physician cleared the member to work, it does not determine that the member if FFD for Navy Reserve service. A sample letter is provided in enclosure (12). If an evaluation by a military physician is not feasible (i.e. member and NOSC are in a remote location w/o access to an MTF), the civilian physician’s note will suffice along with the member’s LOD closure request.

E. If the member is requesting incapacitation pay, complete a LOD Monthly Update/Incapacitation Pay Request, enclosure (13). The command will complete sections I and V, the member has to ensure that sections II, III and IV are completed accordingly. Refer to chapter 6 for guidance.

1) You must specify in section V if the member’s case has been forwarded to the MEB or PEB (if applicable). If not, a justification should be forwarded to the LOD shop (i.e. surgery pending, member has not completed initial medical treatment plan, etc…).

2) You must also state any IDT, IDTT, AT, or ADT performed for the period of incapacitation pay requested. If the member was in a paid duty status during the period requested for incapacitation pay, the member cannot receive incapacitation pay. Even if the member was just given points and not paid for the duty period, DFAS cannot differentiate between the two. This will result in a delay to pay the member until one of the following options address the issue:

(a) The NOSC Personnel section removes the duty period. Once corrected, notify the LOD shop. The LOD shop will inform DFAS to process the incap pay request again.

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(b) The duty period remains and the NOSC Personnel section processes pay for the duty period. If this is the option taken, notify the LOD shop. The LOD shop will generate a “corrected” incap pay request to “pay around” the duty period. This “corrected” pay request will be faxed to DFAS.

F. Review the expiration date of the case. LOD medical/dental benefits are normally valid for a period of 12 months (can be less as determined by PERS-952). Endorse the extension request as indicated. The LOD extension request format is provided in enclosure (14).

1. If the member only receives medical/dental care benefits, an extension request must be submitted one month prior to the expiration of the LOD. Notify the member in advance of this request. The extension is addressed to Commander, Navy Personnel Command (PERS-952). Give details of circumstances as necessary. Ensure that the details are added after the colon punctuation in each line. The LOD medical/dental benefits may be extended from 6-12 months depending on the status of the member’s medical care.

2. If the member receives incapacitation pay benefits, the incapacitation pay extension request will be initiated by the respective PERS-952 LOD program manager 60 days prior to the expiration date. The 1st pay extension is valid for an additional 6 months. All subsequent pay extensions are for 6 month increments, but must be reviewed by BUMED prior to approval by the ASN. Incapacitation pay benefit cannot be extended past the expiration date of the LOD medical/dental benefits.

G. Fax or email the LOD Monthly Update/Incapacitation Pay Request and current medical documentation to your LOD program manager on a monthly basis. Forward any additional correspondence as needed.

H. Upon receipt of correspondence from PERS-952 or CNPC, read the letter in its entirety and endorse it per SECNAVINST 5216.5D to the member. If a case is suspended, the member must provide a medical update to prevent the case from being terminated. If the case is terminated and the member wants to re-open the LOD, a LOD reinstatement request must be submitted. The reinstatement request should include information as to why he or she did not/could not comply with the program requirements and what steps he or she will take to prevent a termination from occurring in the future. Refer to enclosure (15).

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I. If the member wants to take AT or ADT orders while on

LOD status for any reason other than initiation or completion of a MEB or PEB, a waiver request must be submitted to the LOD shop. The member cannot accept the orders without a waiver approved by the LOD shop. An AT/ADT waiver request must be submitted to the LOD shop a minimum of 7 working days prior to the execution date of the orders.

1) Send the request via email with the following information: member’s info, type of orders, length of orders, location of duty, and type of duty to be performed.

2) Upon receipt of the waiver request, the LOD shop will review the request to ensure the following: that the member is compliant with the LOD program requirements, the type of duty to be performed will not exceed the treating physician’s duty limitations, and the location of duty has the appropriate medical support (**NOTE** Any waiver request with a duty location OCONUS will normally not be approved).

3) If the waiver is approved, you will receive a waiver approval letter from the LOD shop.

4) Explain to the member that incapacitation pay cannot be requested for the period of the AT/ADT if the member received pay by the Navy for the duty period (this is also noted on the waiver approval letter).

5) A waiver MUST be requested for each AT or ADT period.

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Chapter 4: Requesting Pay Ref: (a) U.S.C. Title 37, 204(g) (b) MANMED, Chapter 18 (c) U.S.C. Title 37, 204(h) (d) DoDI 1241.2 of 30 May 01 (e) 2006 National Defense Authorization (f) MILPERSMAN Article 7220-460 I. Purpose. To assist you in the preparation of a pay request and to give you an understanding of the two types of incapacitation pays: Full Pay and Allowances and Reimbursement of lost income. Advance pay is not authorized. Pay may only be requested in arrears. II. Definitions.

A. Full pay and allowances: indicates that a member is medically unable to perform a reasonable amount of his/her military duties (cannot perform IDT/IDTT) due to a LOD injury, illness, or disease and may be entitled to Full Pay and Allowances as outlined in reference (a). The member also qualifies for Full Pay and Allowances when the Physical Evaluation Board finds the member “Unfit” or during convalescent period. Per reference (b), convalescent period may be granted for up to 30 days post surgery/hospitalization. If a surgical procedure is performed within a pay cycle, you must submit a split incapacitation pay request. If the member drills during a convalescent period (even if for points only), you must have your command pay clerk remove the drills. If drills appear, DFAS will assume the member was paid and will not process the incapacitation pay request. All non-military income must be declared and is subtracted from a full pay and allowance pay request. While on convalescent leave and the member still receives non-military income, member can still request incapacitation pay. In this instance, member is entitled to Full Pay and Allowances, but any earned income will be subtracted and member will receive the difference.

B. Reimbursement of lost income: indicates that a member is

able to perform a reasonable amount of his/her military duties (i.e. light duty) with the LOD injury, illness, or disease. Per references (c) and (d), any member that experiences a loss of civilian income due to a service related injury is entitled to reimbursement up to but no greater than pay of an active duty counterpart of similar grade and years of service. Loss of

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income must be demonstrated from nonmilitary employment or self-employment. A loss of income can be established in various ways. However, a loss of income is most commonly established when:

1) The treating physician cuts the member’s working hours.

2) A member is terminated from employment (must be related to the LOD injury and in writing from the employer).

3) The employer is unable to accommodate the member’s work limitations (must be in writing).

4) The member takes a pay cut when the employer accommodates member by moving him/her to a new position (must be related to the LOD injury).

5) The member has to take time off to attend medical appointments.

6) If the member utilizes sick/annual leave, there is no loss of income unless the member obtains a letter from his employer that states he/she returned the money that was used for sick/annual leave.

7) In circumstances where a member is self-employed, he/she must provide a copy of the previous year tax return (specifically Schedule “C”) to establish a loss of income. **NOTE** Unemployed members, members that resign, or members that have been medically cleared to work, but choose not to work are not eligible for reimbursement of lost income.

C. Medical documentation: documentation of care provided by a physician, family nurse practitioner, or physician assistant. For members with PTSD, documentation from a certified social worker will be accepted in lieu of a physician’s note. Documentation should, at a minimum, include a diagnosis, prognosis, treatment plan, and limitations. III. Required Forms. A checklist is provided in Appendix C.

A. Initial Request:

1. LOD Monthly Update/Incapacitation Pay Request.

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2. Physician Recommendation/Limitation for Civilian Employment and Military Duty (PR) or Medical Documentation.

3. Current Page 2 (if one was not provided with the LOD

request package).

B. Subsequent Pay Requests:

1. If requesting monthly:

a) LOD Monthly Update/Incapacitation Pay Request.

b) PR or Medical Documentation.

2. If requesting pay bi-monthly:

a) 1st-15th

(1) LOD Monthly Update/Incapacitation Pay.

(2) PR or Medical Documentation. If the member has an appointment later in the month, you must provide the appointment date and send the documentation on the next update.

b) 16th-end of month

(1) LOD Monthly Update/Incapacitation Pay. (2) PR or Medical Documentation, if not

previously submitted. IV. Procedures for requesting pay.

A. For the initial pay request.

1. Counsel the member regarding incapacitation pay using the following Page 13’s (if not previously done).

(a) Member’s Privileges and Responsibilities for LOD Medical Care and Incapacitation Pay Benefits, NAVPERS Form 1070/613

(b) Reporting of Civilian Earned Income or Loss of

Earned Income for Incapacitation Pay Benefits, NAVPERS Form 1070/613

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2. Print the incapacitation pay request form (enclosure

(13)).

3. Forward this form to the member to ensure that they have it before their next doctor visit.

B. Upon receipt of the incapacitation pay request from the member, review the form(s).

1. LOD Monthly Update/Incapacitation Pay

Request, enclosure (13). Review sections I - IV for completion. If any information is missing, contact either the member or the employer to obtain the applicable missing information. If the member is unemployed, state “Unemployed” in section IV and justification MUST be provided to support the claim of lost income. The NOSC CO or “By Direction” representative fills out and signs section V. *IMPORTANT NOTE* the command MUST verify the member’s claim of lost income to include proof of employment and that the member did not receive any other form of income (money received from the VA must be claimed as income). Refer to chapter 6 for guidance.

2. Physician Recommendation/Limitation for Civilian Employment and Military Duty (PR), enclosure (9), or Medical Documentation. Pay will not be authorized if the PR or medical documentation is not provided for the period of pay requested. Refer to chapter 3 for procedures in reviewing the PR or medical documentation.

3. Scan the incapacitation pay request and email it to the LOD shop at lod@navy.mil.

4. Follow-up. Do not call to verify receipt of a package immediately after faxing the incapacitation pay request. Check the status block in MRRS within 3 business days to verify status of the request by PERS-952. If you do not see an updated status, call your LOD program manager at that time. Generally, the pay request is processed within 3 business days. If you do not receive a notification of approval or a request for additional information within that specified timeframe, check the status update tab in MRRS prior to contacting your LOD program manager for a status update. If additional information is requested, you must submit the requested information immediately. The pay request will not be processed until the missing information is received and this will delay the member’s pay.

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Chapter 5: Obtaining Pre-Authorization for Care and Processing Claims

Ref: (a) MILMEDSUPPOFFINST 6320.1(Series) (b) SECNAVINST 1770.3D I. Purpose. To provide guidance in obtaining pre-authorization for medical care from Military Medical Support Office (MMSO) and processing medical claims. MMSO provides: (1) military oversight of the Managed Care Support Contractor’s approval and payment of medical claims; (2) pre-authorization and payment of dental care; and (3) unit notification of “fitness for duty” conditions and assistance in accessing medical care at military treatment facilities (MTFs). This chapter does not apply to Sailors that are referred for civilian medical care from a MTF or that are eligible for the Transitional Assistance Management Program (TAMP) after release from active duty service. Sailors that are eligible for TAMP may refer to the TRICARE website www.tricare.osd.mil/reserve or call 1-888-DOD-CARE. Those that are dual eligible for LOD and TAMP benefits should coordinate their care with their NOSC MDR. *Note* TAMP should not be used for long term medical conditions in lieu of a LOD. If the member’s medical condition requires long term treatment (greater than 6 months), an LOD should be requested immediately. II. Required Forms.

A. Reserve Component Medical Eligibility Verification B. Reserve Component Pre-Authorization Request for Medical

Care C. Pre-Authorization Request for Dental Care D. MMSO Appeal E. MMSO Dental Information Sheet

III. Procedures for obtaining pre-authorization, if required.

A. Establish eligibility for care. To do so, you must send the following information to MMSO based on the category of care rendered:

1. Emergency and/or initial episode of care. Per reference (b), if a RC member incurs and injury/illness while in a duty status, he/she is entitled to emergency medical care. Member’s medical bills will be covered by TRICARE by submitting the following to MMSO:

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a) Reserve Component Medical Eligibility

Verification form, enclosure (16). MMSO requires one Cover Sheet for the emergency and/or initial episode of care.

b) A copy of orders or Inactive Duty Training (IDT) muster sheet.

c) For emergency dental care, follow the dental instruction provided at http://mmso.med.navy.mil. Routine dental care is not authorized without pre-authorization.

2. Follow-up Medical Care. After the initial emergency treatment and member requires additional follow up care, a LOD request must be submitted to PERS-952. Without an approved LOD for follow up care, the member may be subject to pay for incurred medical cost.

a) Reserve Component Pre-Authorization Request for Medical Care, enclosure (17).

b) A copy of approved LOD if it was not previously submitted.

c) You are not required to obtain a pre-authorization for medical care that meets certain criteria. Periodically check the MMSO website at the Reserve Component Instruction webpage for an updated list. Currently, the following medical care does require pre-authorization by MMSO:

(1) The initial episode of emergency medical care does not require preauthorization. However, in order for the claim to be paid, MMSO must receive verification from the member’s unit that the care is a result of a LOD injury or illness.

(2) Except in the case of an emergency, MMSO staff will not provide an authorization for follow-up LOD medical care after the medical care has already been rendered. If you fail to obtain a pre-authorization for follow-up medical treatment, you must contact MMSO for payment of the claim for medical care by first calling 1-888-647-6676.

(3) The plan of care must be preauthorized by MMSO before any further medical care will be authorized or paid. You must request further clarification when in doubt about

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whether a procedure or test requires preauthorization or is a TRICARE covered benefit.

(4) MMSO does not coordinate Military Treatment Facility (MTF) referred medical care or MTF provider orders for TRICARE to pay medical claims. The MTF staff should coordinate the preauthorization of care and the payment of medical claims with their designated regional TRICARE office. If the MTF is unable or unwilling to pre-authorize civilian medical care or facilitate payment of claims for care that is MTF referred, you should contact their respective SPOC for assistance. If you have questions concerning preauthorization requirements, contact the LOD shop (PERS-952) or the MMSO Case Management Division staff at 1-888-647-6676.

B. Obtain pre-authorization for each separate episode of follow-up care. Refer to paragraph A2 for follow-up care procedures.

C. Request pre-authorization for dental care. Refer to enclosure (18) for a sample request letter. IV. Procedures for processing claims.

A. You must submit bills directly to the TRICARE Contractor where the Sailor resides. A medical claim consists of a medical claim from the provider (HCFA 1500, UB 92) and, if applicable, DD Form 2642 (Champus Claim form for Service Member Reimbursement). An example of these forms is available at MMSO’s website http://mmso.med.navy.mil or the TRICARE Prime Remote website www.tricare.osd.mil/remote. The addresses for contractors that process medical claims can also be found on the TRICARE website at www.tricare.osd.mil/claims. If a medical claim is denied, refer to enclosure (19) for guidance. If a dental claim is denied, completed the MMSO Dental Information Sheet, enclosure (20).

B. You are not required to obtain a prior authorization for prescriptions given in conjunction with authorized care with the exception of a few medications. Refer to enclosure (21) for a list of medications that require prior authorization. However, periodically check the Express Scripts for an updated list of prescriptions that require prior authorization at www.tricare.osd.mil/pharmacy/prior_auth.cfm. Additionally, beware that certain medications have quantity limits. Refer to enclosure (22) for a list of medications that have quantity limits. However, periodically check the Express Scripts for an

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updated list of medications that have quantity limits at www.tricare.osd.mil/pharmacy/quant_limits.cfm.

C. For pharmacy reimbursement, submit the following to MMSO for processing: 1) DD Form 2642, 2) a pharmacy billing statement or a paid civilian pharmacy invoice, 3) any eligibility documentation (Orders, attendance roster, or LOD approval letter) if not already on file with MMSO, and 4) RC Eligibility coversheet directly to MMSO. MMSO will coordinate directly with Express Scripts Incorporated (ESI) and instruct to reimburse. If something critical is missing, MMSO will contact the Unit POC on the coversheet to smooth the requirements before sending to ESI for final reimbursement/payment, as ESI does have specific requirements before they will issue a check. Good practice guidance is to ask the retail pharmacists to bill the member. Then, the member can send MMSO the bill directly, while the Unit POC works out the eligibility piece with MMSO, to avoid money being spent upfront. Provide the member’s full SSN on all documents faxed or mailed to MMSO. In addition, you should refer phone calls from a retail pharmacist or an ESI representative concerning eligibility to MMSO. Mail: Military Medical Support Office Attn: RC Retail Pharmacy Reimbursement Box 886999 Great Lakes, IL 60088-6999 Fax: 847-688-6137 Attn: RC Retail Pharmacy Reimbursements

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Chapter 6: Disability Evaluation System (DES) Ref: (a) MANMED, Chapter 18 (b) DoDI 1241.2 of 30 May 01 (c) MILPERSMAN Article 1000-150 (d) SECNAVINST 1850.4E I. Purpose. To give you a general understanding of how the Disability Evaluation System (DES) operates and to identify your responsibilities in the process. The DES identifies the procedures for evaluation of fitness for duty and disposition of physical disability in the Department of the Navy. II. Background. Per references (a) and (b), the Primary Care Manager (PCM) must make the decision to dictate a Medical Evaluation Board (MEB) unless ordered by a convening authority. Commander, Navy Personnel Command (PERS-952) is a convening authority. You must contact the MTF’s Med Board office to initiate the MEB. You will need to have member’s CO complete a Non-Medical Assessment (NMA). Once the member’s MEB has been scheduled at the MTF, the member will be assigned a Physical Evaluation Board Liaison Officer (PEBLO) at the MTF. The PEBLO is there to assist the member in completing the MEB process. The PEBLO will schedule the member to attend the Disability Transition Assistance Program (DTAP) course. Upon completion of DTAP and any addendums, the PEBLO will review the completed MEB package and explain the member’s rights concerning the MEB findings. If the MEB finds the member Fit for Duty and the member agrees, he/she will be returned to a duty status after the LOD is closed. If the member is found Unfit by the MEB, the PEBLO will counsel the member prior to forwarding the MEB package to the Physical Evaluation Board (PEB) for fitness for duty determination. If the Medical Board was completed at an Army or Air Force Treatment facility, the package will be forwarded to a Navy Treatment Facility and then to the PEB. Once the PEB makes a decision, the member is given the following options:

A. Informal PEB

1. If the member is found “Fit for Continued Naval Service” and member does not agree with the finding, he/she may:

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a) Request Reconsideration by the PEB. *Note* PEB does not have to grant a reconsideration. They can deny the member’s request and the informal PEB findings will be final.

2. If the member is found “Unfit for Continued Naval Service” and member does not agree with the finding or with the disability percentage, he/she may:

a) Appeal to the Formal PEB. The member will be

notified of the Formal Board date by the PEBLO.

3. Acceptance of findings.

a) If the member accepts the Fit finding, PERS-952 will close the LOD upon receipt of the PEB Index notification. Once the LOD is closed, member is returned to a duty status.

b) Upon the member’s acceptance of the Unfit

finding, he/she is given the following options:

(1) If the member is rated 10%-20% disabled, he or she will be separated with severance pay. Severance pay is based on active duty time. If the member accepts the severance pay, they forfeit any retirement benefits (if applicable).

(2) If the member has been rated 10%-20%

disabled; the member can choose to accept the Unfit finding, but waive the severance pay in order to request the following retirement options if they qualify: Early Retirement (15-20 years of qualifying service) or Non-Regular Reserve Retirement (>20 years of qualifying service).

(3) If the member is rated 30% or higher, he or

she will be transferred to the Temporary Disability Retirement List (TDRL) or to the Permanent Disability Retirement List (PDRL), as applicable. Pay will be based on grade and time in service.

B. Formal PEB

1. If the member is found “Fit for Continued Naval

Service”, he/she may:

a) Accept findings.

b) Request a Petition for Relief (PFR).

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2. If the member is found “Unfit for Continued Naval Service”, he/she may:

a) Accept findings. b) Request a Petition for Relief (PFR).

3. The member’s options for separation are the same as

stated in Chapter 6, A, 2.

4. Once the member requests a PFR, their LOD will remain open until receipt of the final finding. **NOTE** As with all findings, the member has 15 days to reply. On the 16th day and the PEB has not received a reply from the member, the PEB will rule that the member has “presumed acceptance” of the finding. The finding of the respective board will be final.

5. Once the case has been finalized, the PEB will release the PEB Index findings. Upon receipt of the PEB Index, PERS-821 releases a separation message and the command executes the message. If the member insists that there was an error or injustice, he/she has the right to appeal to the Board for Correction of Naval Records (BCNR). Refer to reference (c) for guidance. III. Procedures for initiating a Med Board.

A. If PERS-952 instructs you to initiate a MEB, contact the Med Board office at the nearest MTF (preferably a Navy MTF, but other DoD MTF’s may be used). You may be required by the MTF to prepare a Consultation Sheet (SF-513), see enclosure (23). This step is not necessary if the MTF initiates the MEB. Refer to the following for the appropriate entry on the SF-513:

1. For a Navy MTF – “This member was issued a Line of Duty (LOD) by Commander, Navy Personnel Command (PERS-952) for LIST CONDITION(S) incurred or aggravated on Date of Injury. The member has been undergoing treatment for length of treatment. The member has achieved maximum medical benefits and has not been found Fit for Duty. In accordance with MANMED Chapter 18, a Medical Evaluation Board (MEB) is required in order to determine the member’s fitness for duty. Request that a MEB be convened immediately and a copy be forwarded to Your NOSC upon completion.”

2. For other DoD MTF – “This member was issued a Line of Duty (LOD) by Commander, Navy Personnel Command (PERS-952)

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for LIST CONDITION(S) incurred or aggravated on Date of Injury. The member has been undergoing treatment for length of treatment. The member has achieved maximum medical benefits and has not been found Fit for Duty. In accordance with DoDI 1241.2 of 30 May 01. Request that a Medical Evaluation Board be convened immediately and forward the completed evaluation to Your NOSC or designate a Navy MTF for endorsement to the Physical Evaluation Board.”

B. Enter the date that the MEB is scheduled in MRRS. You will get this date from the MTF when you contact them to request the MEB.

1. Open MRRS. 2. Move the mouse over “Injury Management”.

3. Move the mouse over “Reserve Component”.

4. Move the mouse over “LOD”.

5. Click “LOD Update”. 6. Enter the last four of the member’s social security

number and click “Apply”. 7. Open the record that you want to edit. 8. Click on the “Med Board” tab.

a) Enter the appointment date. In addition, fill

in the point of contact information.

b) Once the Med Board is completed, enter the date completed and date forwarded to the PEB.

c) If the Med Board was not conducted on specified date, make a note in the “Medical Board Not Initiated” block.

9. Press “Save”.

C. Instruct the member’s CO to complete a Non-Medical

Assessment (NMA), enclosure (24). The NMA must be completed within 15 days. If the unit cannot complete the NMA within the specified period, your CO must complete the NMA based on a personal interview and information in the member’s service

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record. The MEB will not be forwarded to the PEB without an NMA.

D. Schedule the member for a physical exam.

E. Once the MEB is complete and package has been forwarded to the PEB, contact the member or PEBLO to obtain a complete copy the MEB package. Forward this package to PERS-952 and retain a copy in the member’s record.

F. Once the PEB is complete, obtain a complete copy of the signed PEB findings. Upon receipt, forward a copy to PERS-952 and retain a copy in the member’s record. PERS-952 will include this in the member’s case file, but will not close the LOD until it has received the PEB Index.

G. Once the member has accepted the PEB findings or exhausted all appeals, PERS-821 will send your command the separation message (if applicable). If you have not received the message, contact the LOD shop to get a copy of the message.

H. Forward the message to your personnel department or supporting Personnel Support Detachment (PSD) for action. Contact the separation or retirement section for assistance. Refer to enclosure (25) as a guide.

36

Chapter 7: Medical Retention Review (MRR) packages submitted to

the Physical Evaluation Board (PEB) Ref: (a) BUPERSINST 1001.39F (b) SECNAVINST 1850.4E (c) SECNAVINST 5216.5D 1. Purpose. To give you guidance when submitting Medical Retention Review (MRR) packages to the Physical Evaluation Board (PEB). 2. Background. Per reference (a), when a Sailor has a potentially disqualifying condition, a Medical Retention Review (MRR) package must be submitted. The package is forwarded to Commander, Navy Personnel Command PERS-952 (Officers & Enlisted) via the Echelon 4 command, and Chief, Bureau of Medicine and Surgery (BUMED) (M32). BUMED (M32) reviews the available information and recommends a risk classification code to CNPC (PERS-952). PERS-952 reviews the MRR package along with the BUMED recommendation and assigns a Physical Risk Classification (PRC) code. If the Sailor is assigned a PRC “5”, one of the options he/she has is to request a review by the PEB. Do not confuse the Medical Retention Review (MRR) process with the Medical Evaluation Board (MEB) process. Although both processes are evaluated by the PEB, there are distinct differences between the two. A RC member with an injury, illness, or disease that is not service-connected is processed for an MRR. MRR cases receive Physically Qualified (PQ) or Not Physically Qualified (NPQ) findings from the PEB and receive no disability benefits from the Navy. 3. Required Forms. A checklist is provided in Appendix E.

A. Member letter requesting PEB. B. Physical examination (within 6 months). C. Original retention package. D. Non-Medical Assessment (NMA). E. BUMED determination letter. F. PERS determination letter. G. LOD Understanding. H. Member’s election of PEB review.

37

4. Processing a PEB package. This assumes that you have received the PERS PRC “5” determination and the member requested a review by the PEB.

A. Schedule the member for a physical exam.

B. Assist in preparing and obtaining the forms.

1. Member’s letter requesting a PEB, enclosure (26). Assist the member in preparing this letter per reference (c).

2. Physical exam. Ensure that is completed prior to

forwarding the PEB package and must be within six months. 3. Non-Medical Assessment, enclosure (24). Instruct the

Unit CO to complete a Non-Medical Assessment (NMA). The NMA must be completed within 15 days. If the unit cannot complete the NMA within the specified period, your CO must complete the NMA based on a personal interview and information in the member’s service record.

4. LOD Understanding, enclosure (27). Ensure that the

member initials and signs the applicable blocks. PERS-952 LOD section will review the package for LOD benefits if the member believes that his or her medical condition is Navy Reserve service related.

5. Member’s election of PEB review. Ensure that the

member initials and signs the applicable blocks.

C. Once the package is completed, prepare an endorsement per reference (c).

D. Present the PEB package for signature to your Commanding

Officer. The package may be signed “By direction”. E. Forward the PEB package to your RCC for endorsement prior

to submission to COMNAVPERSCOM (PERS-952). F. Follow-up. Verify that the PEB package has been endorsed

by the applicable commands and forwarded to PERS-952. Once the package is received by PERS-952, the status will be updated in MRRS. Generally, the PEB package is processed within 14 workdays. Check the status update tab in MRRS prior to contacting PERS-952 for a status update. If additional information is requested, you must submit the requested information within 30 days.

38

G. If the member notes on the LOD Understanding form that

their condition was service connected, the MRR package will be forwarded by the MRR section to the LOD section for review. You will be notified by the MRR section for any additional information required for an LOD determination (if not already included in the MRR package). Your NOSC will receive notification of the LOD determination either from CNPC or the LOD shop.

1. If the LOD is approved, the MRR case will be closed in MRRS. The member will have an LOD case opened in MRRS by the LOD section (PERS-952). Refer to Chapter 3 for management of the LOD case.

H. If the LOD is denied and the member does not agree,

he/she has the option to appeal the decision. Have the member submit their intention to appeal writing. Refer to chapter 2 for information pertaining to appeals to OJAG.

I. If the member has exhausted all appeals and the condition

is still found to be not service connected, the PERS PRC “5” status still stands and the member should continue to be processed in accordance with reference (a).

39

Enclosures

(The following enclosures are current as of the review date of this guide. For the most up to date version of these enclosures,

please visit the PERS-95 website at http://www.npc.navy.mil/CareerInfo/ReservePersonnelManagement

/Medical/)

Encl (1)

ADMINISTRATIVE REMARKS NAVPERS 1070/613 S/N 0106-LF-010-6991

E-32

SHIP OR STATION

REFUSAL OF LINE OF DUTY (LOD) BENEFITS (Initial each block.) I understand that I may have incurred or aggravated an injury, illness, or disease while in a Navy Reserve duty status. If eligible, I may be entitled to medical care until my condition improves and I am found Fit For Duty or processed through the Disability Evaluation System (DES). I understand that I may be eligible for incapacitation pay until I am found Fit for Duty (FFD) or processed through the DES per SECNAVINST 1770.3D. I understand if I am processed through the DES and found Unfit by the Physical Evaluation Board that I may be eligible for Separation with Severance Pay, Temporary/Permanent Disability Retirement, or Non-regular Reserve Retirement. I certify that my rights have been thoroughly explained and I understand my entitlements concerning a LOD. I, , hereby waive all LOD benefits I may have been entitled to per SECNAVINST 1770.3D and SECNAVINST 1850.4E. I understand that I have 60 days to retract this refusal of LOD benefits. At the expiration of this period, I understand that I may not apply for LOD benefits for this particular injury, illness, or disease in the future. If I have any complications after the 60-day retraction period, I acknowledge that although this condition may have been service-related, I waived my LOD benefits. I hereby acknowledge that I may be processed for administrative separation if my medical condition prevents me from fulfilling my Navy Reserve duties. Knowing this, I release the United States Navy from all responsibilities and will accept all liabilities from any complications arising from the injury, illness, or disease in the future. I am waiving LOD benefits for (injury/illness/disease) that I may have incurred or aggravated during a duty period on (date of injury/illness/disease). I do so under no duress and of my own freewill. ___________________________________ ___________________________________ (Witness Signature) (Member’s Signature) ___________________________________ ___________________________________ (Witness Printed Name) (Member’s printed name) ___________________________________ ___________________________________ (Date Signed) (Date Signed ) NAME (Last, First, Middle) SSN BRANCH AND CLASS

USN

13

LOD REQUEST FORMAT 1770

Ser Date From: Commanding Officer, Activity To: Commander, Navy Personnel Command (PERS-952) Subj: REQUEST FOR LINE OF DUTY (LOD) BENEFITS FOR RANK/RATE NAME, USN, SSN/DESIG Ref: (a) SECNAVINST 1770.3D Encl: (1) Report of Investigation Line of Duty and Misconduct Status (DD 261) (2) Statement from witness (if applicable) (3) Copy of LOD Privacy Act (4) Copy of orders/DD214/Drill Muster sheet at time of incident (5) Copy of Motor Vehicle Accident Report (if applicable) (6) Authorization for Disclosure of Medical or Dental Information (DD 2870) (7) Copy of Physical exam (DD-2807/DD-2808) (8) Copy of PHA (9) Copy of PFA screening (if applicable) (10) Copy of Emergency Room Report concerning injury, illness, or diagnosis (if applicable) (11) Copy of Medical Documentation from time of incident (12) Copy of Chronological Medical Care pertaining to injury, illness or diagnosis (if applicable) 1. Per reference (a), enclosures (1) through (12) are submitted with the following information: a. Reservist’s full name, rank/rate/grade, SSN, organizational unit and unit identification code (UIC):. b. Command name, address, and UIC:. c. Duty status at the time of incident. (i.e. IDT, IDTT, AT, ADT, ADSW, PRC) Provide time and dates of duty period. Provide copy of DD214 for all orders greater than 30 days:. d. Date, place, and circumstances of injury, illness or disease:. e. Diagnosis or description of the nature of the injury, illness or disease:. f. If hospitalized, the name of the facility, date and time of admission, admission diagnosis, and an early estimation of hospital stay. If hospitalized in a nonfederal facility, name and address of attending physician, and telephone number of the patient administration officer. (Note: except for emergencies all civilian care must be authorized by Military Medical Support Office (MMSO), Great Lakes, IL. A copy of the LOD request letter, without enclosures, should be forwarded to MMSO, if hospitalized in a nonfederal facility:.

Encl (2)

2

Subj: REQUEST FOR LINE OF DUTY (LOD) FOR RANK/RATE NAME, USN, SSN/DESIG g. Commanding Officer’s determination as to whether or not the injury/illness, or disease was incurred in the line of duty. Per the Navy JAGMAN Article 0229, the Commanding Officer should perform an interim line of duty investigation within 7 days if required by the circumstances of the injury/illness or disease:.

h. Member’s complete home address, telephone number and E-mail:. i. Member’s civilian occupation:. j. Pay entry base date:. k. Dependency status:. l. Location of member’s health record when member is not in a duty status:. m. If the LOD request is submitted more then 10 days after the condition occurs, an explanation for submission delay is required:. n. Commanding officer recommendation on whether “Drilling” or Non-drilling” LOD is requested, with justification:. 2. Name, E-Mail, telephone number, and fax number of the point of contact responsible for responding to inquiries for the LOD request.

C. O. SIGNATURE

ADMINISTRATIVE REMARKS NAVPERS 1070/613 S/N 0106-LF-010-6991

E-32

SHIP OR STATION

LOD PRIVACY ACT STATEMENT Authority: Reservist who request Line of Duty Benefits. 10 United States Code 1074a and SECNAVINST 1770.3 (Series) Principle purpose: To determine eligibility for LOD benefits provided by law for a medical or dental condition incurred during or aggravated by Navy Reserve service requiring medical or dental care that extends beyond the termination of the current duty period. Routine Uses: Statements made in support of an investigation are routinely made available to the Veterans Administration for use in ascertaining eligibility for Veteran’s benefits; to the Serviceman’s Group Life Insurance (SGLI) for proceeds; and to the U.S. Department of Justice for use in litigation involving the Government. Disclosure is voluntary. You are advised that you are presumed to have questions regarding line of duty determination resolved in your favor. If you do not provide the requested information, you may preclude each entitlement to Reservist Disability and Death Benefits, Veterans’ Benefits, and SGLI proceeds to the Reservist (or their survivors) who is the subject of this investigation.

WARNING REQUIRED BEFORE REQUESTING STATEMENTS REGARDING DISEASE OR INJURY You are hereby advised as follows: You need not sign any statement relating to the origin, occurrence, or aggravation of a disease or injury incurred by you or another. Any such statement signed by you with out a valid waiver of this right is of no force and effect. I do/do not (circle your intent) desire to submit a statement. ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ___________________________________ ___________________________________ (Witness Signature) (Member’s Signature) ___________________________________ ___________________________________ (Witness Printed Name) (Member’s printed name) ___________________________________ ___________________________________ (Date Signed) (Date Signed) NAME (Last, First, Middle) SSN BRANCH AND CLASS

USN

13

Encl (3)

DD FORM 261, OCT 95(EG) PREVIOUS EDITION WILL BE USED Encl (4)

REPORT OF INVESTIGATION LINE OF DUTY AND MISCONDUCT STATUS

1. REPORT DATE (YYMMDD)

2. INVESTIGATION OF (X one) 3. STATUS (X as applicable) INJURY DISEASE ILLNESS DEATH a. REGULAR OR EAD 4. TO (Major Army or Air Force Commander) b. CALLED TO AD FOR Deputy Chief of Naval Operations (Manpower, Personnel, Training & Education) (N1)

(1) MORE THAN 30 DAYS (2) 30 DAYS OR LESS

5. NAME OF INDIVIDUAL (Last, First, Middle Initial) 6. SSN 7. GRADE

c. INACTIVE DUTY TRAINING (Type)

8. ORGANIZATIONAL AND STATION

d. SHORT TOUR OF ACTIVE DUTY FOR

TRAINING 9. OTHER MILITARY PERSONNEL INVOLVED IN THE SAME INCIDENT

NAME (Last, First, Middle Initial) a.

SSN b.

GRADE c.

d. LOD INVESTI- GATION MADE (X) e. DURATION (Applies ONLY to 3.c. and d.)

YES NO DATE (YYMMDD) HOUR

(1) START (2) FINISH 10. BASIS FOR FINDINGS (As determined by investigation)

a. CIRCUMSTANCES (1) HOUR (2) DATE (3) PLACE

(4) HOW SUSTAINED b. MEDICAL DIAGNOSIS

c. PRESENT FOR DUTY? (X)

d. IF ABSENT: (X) (Do not complete 10.e. and f. in death

cases.)

e. WAS INTENTIONAL MISCONDUCT OR NEGLECT THE PROXIMATE CAUSE? (X)

f. WAS INDIVIDUAL MENTALLY SOUND? (X) WITH AUTHORITY

YES NO WITHOUT AUTHORITY YES NO YES NO g. REMARKS

11. FINDINGS (X one. Do not complete in death cases.) IN LINE OF DUTY NOT IN LINE OF DUTY – NOT DUE TO OWN MISCONDUCT NOT IN LINE OF DUTY – DUE TO OWN MISCONDUCT

12. INVESTIGATING OFFICER a. TYPED NAME (Last, First, Middle Initial) b. GRADE c. BRANCH OF SERVICE d. SSN e. ORGANIZATION AND STATION f. SIGNATURE

13. ACTION BY APPOINTING AUTHORITY 14. ACTION BY REVIEWING AUTHORITY a. HEADQUARTERS b. DATE (YYMMDD) a. HEADQUARTERS b. DATE (YYMMDD) c. (X one. Indicate reasons and substituted findings on back.) c. (X one. Indicate reasons and substituted findings on back.) APPROVED DISAPPROVED APPROVED DISAPPROVED d. TYPED NAME (Last, First, Middle Initial) d. TYPED NAME (Last, First, Middle Initial) e. GRADE f. BRANCH OF SERVICE g. SSN e. GRADE f. BRANCH OF SERVICE g. SSN f. SIGNATURE f. SIGNATURE

15. FINAL APPROVAL (For action of office indicated in Item 4.)

2

16. NAME OF INDIVIDUAL (Last, First, Middle Initial) 17. SSN 18. GRADE

19. APPOINTING AUTHORITY – REASONS AND SUBSTITUTED FINDINGS 20. REVIEWING AUTHORITY – REASONS AND SUBSTITUTED FINDINGS 21. APPROVING AUTHORITY – REASONS AND SUBSTITUTED FINDINGS DD FORM 261(BACK), OCT 95

DD FORM 2870, DEC 2003 Encl (5)

AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION

PRIVACY ACT STATEMENT In accordance to the Privacy Act of 1974 (Public Law 93-579), the notice informs you the form and howit will be used. Please read it carefully. AUTHORITY: Public Law 104-191; E.O. 9397 (SSAN); DoD 6025.18-R. PRINCIPAL PURPOSE(S): This form is to provide the Military Treatment Facility/Dental Treatment Facility/TRICARE Health Plan with a means to request the use and or disclosure of an individual's protected health information. ROUTINE USE(S): To any third party or the individual upon authorization for the disclosure from the individual for: personal use; insurance; continued medical care; school; legal; retirement/separation; or other reasons. DISCLOSURE: Voluntary. Failure to sign the authorization form will result in the non-release of the protected health information. This form will not be used for the authorization to disclose alcohol or drug abuse patient information from medical records or for authorization to disclose information from records of an alcohol or drug abuse treatment program. In addition, any use as an authorization to use or disclose psychotherapy notes may not be combined with another authorization except one to use or disclose psychotherapy notes.

SECTION I - PATIENT DATA1. NAME (Last, First, Middle Initial) 2. DATE OF BIRTH (YYYYMMDD) 3. SOCIAL SECURITY NUMBER

4. PERIOD OF TREATMENT: FROM – TO (YYYYMMDD) 5. TYPE OF TREATMENT (X one)

OUTPATIENT INPATIENT BOTH SECTION II – DISCLOSURE

6. I AUTHORIZE TO RELEASE MY PATIENT INFORMATION TO: (Name of Facility/TRICARE Health Plan)a. NAME OF PHYSICIAN, FACILITY, OR TRICARE HEALTH PLAN b. ADDRESS (Street, City, State, and ZIP Code)

Commander, Navy Personnel Command (PERS-952) Bldg 768, Rm 115 5720 Integrity Drive Millington, TN 38055-0000

c. TELEPHONE (Include Area Code) (901) 874-4229 d. FAX (Include Area Code) (901) 874-2689 7. REASON FOR REQUEST/USE OF MEDICAL INFORMATION (X as applicable) PERSONAL USE CONTINUED MEDICAL CARE SCHOOL

INSURANCE RETIREMENT/SEPARATION LEGAL OTHER (Specify)

8. INFORMATION TO BE RELEASED

9. AUTHORIZATION START DATE (YYYYMMDD) 10. AUTHORIZATION EXPIRATION

DATE (YYMMDD) ACTION COMPLETEDSECTION III - RELEASE AUTHORIZATION

I understand that: a. I have the right to revoke this authorization at any time. My revocation must be in writing and provided to the facility where my medical records are kept or to the TMA Privacy Officer if this is an authorization for information possessed by the TRICARE Health Plan rather than an MTF or DTF. I am aware that if I later revoke this authorization, the person(s) I herein name will have used and/or disclosed my protected information on the basis of this authorization. b. If I authorize my protected health information to be disclosed to someone who is not required to comply with federal privacy protection regulations, then such information may be re-disclosed and would no longer be protected. c. I have a right to inspect and receive a copy of my own protected health information to be used or disclosed, in accordance with the requirements of the federal privacy protection regulations found in the Privacy Act and 45 CFR - 164.524. d. The Military Health System (which includes the TRICARE Health Plan) may not condition treatment in MTFs/DTSs, payment by the TRICARE Health Plan, enrollment in the TRICARE Health Plan or eligibility for TRICARE Health Plan benefits on failure to obtain this authorization. I request and authorize the named provider/treatment facility/TRICARE Health Plan to release the information described above to the named individual/organization indicated. 11. SIGNATURE OF PATIENT/PARENT/LEGAL REPRESENTATIVE 12. RELATIONSHIP TO PATIENT (If applicable) 13. DATE (YYYYMMDD)

SELF

SECTION IV – FOR STAFF USE ONLY (To be completed only upon receipt of written revocation) 14. X IF APPLICABLE: 15. REVOCATION COMPLETED BY 16. DATE (YYYYMMDD

AUTHORIZATION REVOKED

17. IMPRINT OF PATIENT IDENTIFICATION PLATE WHEN AVAILABLE SPONSOR NAME: FMP/SPONSOR SSN: SPONSOR RANK: BRANCH OF SERVICE: PHONE NUMBER:

Encl (6)

ADMINISTRATIVE REMARKS NAVPERS 1070/613 S/N 0106-LF-010-6991

E-32

SHIP OR STATION

MEMBER'S PRIVILEGES AND RESPONSIBILITIES FOR LINE OF DUTY (LOD) MEDICAL CARE AND/OR

INCAPACITATION PAY BENEFITS _____ 1. Read and initial each block. If I do not understand any portion of this page 13, I must ask my Medical Department Representative (MDR) for clarification prior to initialing the block. _____ 2. I have been notified this date ____________________, that I have been placed in a LOD eligible status. _____ 3. I understand the LOD authorization letter does not constitute as creditable active/inactive duty. _____ 4. If I am unable to perform my military duties, I have either been placed on convalescent leave, Non-Drilling LOD, or the Physical Evaluation Board has found me Unfit for duty, during these periods of incapacitation, I am not authorized to perform IDT, IDTT, ADT, AT, ADSW, or Recall to Active Duty. During this period of incapacitation I may complete correspondence courses to maintain my satisfactory participation for retirement purposes. _____ 5. If I am able to perform my military duties in a light duty status, I have been placed on a Drilling LOD. I may continue to perform IDT and request CNPC (PERS-952) to perform AT or ADT via my command. I may also perform AT or ADT to attend a medical appointment or to complete a medical board, with approval from CNPC (PERS-952). I understand I must provide the following information when requesting training orders: type of orders, length of orders, location where the duty will be performed and what duties will be performed, current diagnosis, prognosis, treatment plan, and duty limitations as indicated by the treating physician. _____ 6. Incapacitation Pay Benefits; I understand that while receiving incapacitation pay benefits whether for reimbursement of lost civilian wages or full pay and allowances it will not exceed military pay and allowances for my pay grade and time of service. _____ 7. Incapacitation Pay Benefits; I understand my medical condition and civilian gross earned and/or lost income will be verified by my command and CNPC (PERS-952) with my employer in order to determine compensation. I understand that it is my responsibility to provide accurate documentation from my employer (whether employed or self employed) that demonstrates ALL earned or lost income. _____ 8. Incapacitation Pay Benefits; I understand that receipt of my incapacitation pay depends on providing the necessary pay documentation every 30 days to my command, failure to do so will delay, suspend or terminate my benefits. _____ 9. Incapacitation Pay Benefits; I understand that I am responsible to present to my civilian employer LOD Monthly update/Incapacitation Pay request form for completion and to explain its use and implications of my incapacitation status. I also understand that this form must be completed and signed by my employer. It will include my civilian gross income earned and/or lost for the period I am requesting incapacitation pay. _____ 10. If necessary and with the assistance of my MDR, I will initiate a request to extend my LOD benefits 30 days prior to the expiration of LOD benefits. _____ 11. I understand that I am eligible for medical/dental care for only the specific diagnosis/condition as stated on my LOD approval letter. Medical/dental treatment costs from a civilian provider not authorized on the LOD will not be covered. Additionally, medical/dental treatment not authorized on the LOD but received from a Military Treatment Facility (MTF) will not constitute continued or additional LOD entitlements or care. _____ 12. While receiving LOD benefits, I understand that I will not normally be transferred to the Voluntary Training Unit or placed In Assignment Processing (IAP), unless it is appropriate to do so for administrative purposes, i.e.(High Year Tenure). _____ 13. I understand that I must see a physician every 30 days and provide the medical documentation to CNPC (PERS-952) via my command. I also understand that incapacitation pay will not be authorized if I miss a medical appointment or do not provide the required documentation when requesting incapacitation pay. _____ 14. I understand that I am responsible to return all medical consults and/or medical documentation to my command within 5 days of the appointment and inform my MDR of my next scheduled appointment.

Page 1 of 2 NAME (Last, First, Middle) SSN BRANCH AND CLASS

USN

13

2

ADMINISTRATIVE REMARKS NAVPERS 1070/613 S/N 0106-LF-010-6991

E-32

SHIP OR STATION

MEMBER'S PRIVILEGES AND RESPONSIBILITIES FOR LINE OF DUTY (LOD) MEDICAL CARE AND/OR

INCAPACITATION PAY BENEFITS (Con’t) _____ 15. I understand that civilian medical/dental care is not authorized without prior authorization from the Military Medical Support Office (MMSO), unless it is an emergency. Additionally, I understand that medical/dental care from a MTF is not authorized without an approved LOD document, unless it is an emergency. _____ 16. I understand that if I fail to obtain prior approval for civilian medical/dental care from MMSO via my MDR that I will be responsible for any bills incurred. I must keep my MDR informed of scheduled medical appointments in order for prior authorization to be obtained from MMSO. _____ 17. I understand all prescription medication I have paid for out pocket maybe reimbursed by completing a DD 2642 Patients Request for Medical Payment form sent to MMSO with a copy of the LOD approval letter. _____ 18. I understand that it is my responsibility to notify my MDR if I am unable to attend a scheduled medical appointment. _____ 19. I understand that it is my responsibility to notify my MDR of any new injury/illness I incur. _____ 20. I understand that while receiving LOD benefits, I may be referred for a Medical Evaluation Board (MEB) within 90 days or when directed by CNPC (PERS-952). _____ 21. I understand that if evidence presented in my case determines my condition was not incurred in the line of duty my benefits may be terminated. _____ 22. I understand that I am responsible for providing an accurate job description of my civilian job (endorsed by my employer) to my physician in order for him/her to assess my duties to determine if I am able to perform my civilian job. _____ 23. I understand that I am responsible to provide my physician with a copy of the Physician's Recommendations/ Limitations for Employment form. Once completed, it is my responsibility to provide a copy to my civilian employer demonstrating any limitations imposed by my physician due to my injury/illness. _____ 24. I understand that if I am able to perform my civilian job that I will do so. Additionally, I understand that the goal of the U.S. Navy is to return me to a military Fit for Duty status and the ability/inability to perform my civilian employment does not affect that determination. _____ 25. I understand that while receiving LOD benefits, I can transfer to another command with approval from CNPC (PERS-952) and the receiving command. _____ 26. I have been advised and understand that the instruction that governs the LOD program is the SECNAVINST 1770.3 (Series). It is my responsibility to read this instruction and any references that pertain to it. I also understand that I am responsible to utilize my chain of command to resolve any questions/issues pertaining to my LOD. _____ 27. I have received a copy of the LOD instruction from my MDR. ___________________________________ ___________________________________ (Witness Signature) (Member’s Signature) ___________________________________ ___________________________________ (Witness Printed Name) (Member’s printed name) ___________________________________ ___________________________________ (Date Signed) (Date Signed )

Page 2 of 2 NAME (Last, First, Middle) SSN BRANCH AND CLASS

USN

13

Encl (7)

ADMINISTRATIVE REMARKS NAVPERS 1070/613 S/N 0106-LF-010-6991

E-32

SHIP OR STATION

REPORTING OF CIVILIAN EARNED INCOME OR LOSS OF EARNED INCOME FOR INCAPACITATION PAY BENEFITS

Per SECNAVINST 1770.3 (Series), while in a Line of Duty (LOD) eligible status and receiving Incapacitation Pay benefits, all personnel are required to report all civilian gross earned income and/or loss of earned income. Civilian earned income is defined as income received from non-military employment or self-employment including but not limited to salaries, wages, tips commissions, professional fees, workers’ compensation, income from an income protection plan, vacation leave or sick leave. Per MILPERSMAN 7220-380 and DOD Directive 1241.1 I may not receive dual compensation from the United States government. Dual compensation consists of retired or retainer pay, disability compensation from the Department of Veteran Affairs or drawing a federal pension. I will notify Commander, Navy Personnel Command (PERS-952) of any and all changes in may pay status while I am receiving incapacitation pay benefits. While injured and receiving incapacitation pay from PERS-952, I will submit claims for the loss of income from my civilian occupation, not to exceed military pay and allowances for my pay grade and time of service. I make the foregoing statement as a part of my claim, with full knowledge of the penalties involved for willfully making a false statement or claim. The U.S. Code, Title 18, Sec. 287, provides a penalty of not more than $10,000 fine or more than 5 years imprisonment or both. ___________________________________ ___________________________________ (Witness Signature) (Member’s Signature) ___________________________________ ___________________________________ (Witness Printed Name) (Member’s printed name) ___________________________________ ___________________________________ (Date Signed) (Date Signed) NAME (Last, First, Middle) SSN BRANCH AND CLASS

USN

13

LOD APPEAL FORMAT From: RANK/RATE Name, USN, SSN/DESIG To: Office of the Judge Advocate General (Code 13) Via: (1) Commanding Officer, Activity

(2) Commander, Navy Personnel Command Subj: APPEAL OF DENIAL OF LINE OF DUTY (LOD) BENEFITS

Encl: (1) Additional information (2) ADCNO ltr (enter serial number and date) (3) Original LOD request package 1. Based on the additional information that I have provided, I am appealing the decision of Commander, Navy Personnel Command. 2. The member must explain in detail the reason why he or she believes that the denial should be overturned along with the circumstances surrounding the request. The additional information must prove that the injury, illness, or disease was incurred or aggravated during a duty period. If the member is submitting an appeal related to a reinstatement request, he or she must provide additional information that the injury was aggravated during a subsequent duty period after being found fit, that his or her case was closed erroneously, or that his or her Medical Department Representative failed to submit monthly medical updates. 3. If you have questions, you may contact me at (xxx) xxx-xxxx.

J. O. SAILOR

Encl (8)

Physician’s Recommendations/Limitations for Civilian Employment and/or Military Duty

From: To: (Physician’s Name - Please Print) (Command) (Address) (Address) (City) (State) (Zip) (City) (State) (Zip) (Point of Contact) (Telephone) (MDR Name) (Telephone) incurred a/an while performing Naval Reserve service. It is the desire of the U.S. Navy to avoid any loss of employment to this member’s company, to return the employee to his/her civilian employment as soon as possible, and to return to military duty. Completion of the following information will assist the employer in determining the employee’s ability to perform the duties of his/her position with their injury/illness and will assist the U.S. Navy in evaluating the member for military entitlements. Please be aware that as this member recovers the diagnosis and degree of disability may improve, thereby allowing member to return to his/her position with or without limitations. An update is required from each follow-up. (Member’s Position) (Describe member’s specific civilian duties) (Describe member’s specific civilian duties (Con’t)) 1. Brief History of injury/disease/medical condition: 2. Physical examination findings this visit: 3. How do these physical examination findings compare to the last physical examination findings?

Encl (9)

2

4. What plan of action must the member follow before his/her next scheduled appointment? 5. When is the member’s next appointment? . (Date) 6. At this point, is the member being considered or scheduled for surgery? Yes or No (circle one) a. If no, what type of alternative treatment is the member currently undergoing and how long? b. If yes, when? . (Date) c. If member already had surgery, what was the date of surgery? . (Date) 7. What type of limitations had been placed on the member, i.e. bed rest? 8. Is this member able to perform the duties of his/her civilian position as described on page 1? Yes or No (circle one) a. If no: (1) What is the estimated period of time the member will be unable to perform the duties of his/her civilian employment, i.e. 6 weeks? . (2) When will this member be able to return to his/her civilian employment? . (Date) 9. Is this member able to perform his/her military duty in a light duty status? Yes or No (circle one) a. If no: (1) What is the estimated period of time the member will be unable to perform his/her military, i.e. 6 weeks? . (2) When will this member be able to perform his/her military duty in a light duty status? .

(Date) 10. When will this member be Fit for Duty (FFD)? . (Date) (Physician’s Signature) (Physician’s Printed Name) (Date) *A Physician, Physician Assistant, or Family Nurse Practitioner may only sign this form. If actual medical notes are available and submitted for the monthly update, this form is not required.

LOD MODIFICATION REQUEST FORMAT

1770 Date From: RANK/RATE Name, USN, SSN To: Commander, Navy Personnel Command (PERS-952) Via: Commanding Officer, Activity Subj: MODIFICATION OF LINE OF DUTY (LOD) BENEFITS Ref: (a) SECNAVINST 1770.3D Encl: (1) Medical documentation 1. Per reference (a), request a modification to my LOD benefits to include the diagnosis of <diagnosis>. 2. Per enclosure (1), <diagnosis> was incurred or aggravated during the duty status. or 2. Per enclosure (1) <diagnosis> was a direct result of the original diagnosis. 3. Name, E-Mail, telephone number, and fax number of the point of contact responsible for responding to inquiries for the modification request.

J. O. SAILOR

Encl (10)

LOD CHANGE REQUEST FORMAT 1770 Date From: RANK/RATE Name, USN, SSN To: Commander, Navy Personnel Command (PERS-952) Via: Commanding Officer, Activity Subj: CHANGE OF LINE OF DUTY (LOD) BENEFITS Ref: (a) SECNAVINST 1770.3D Encl: (1) Medical documentation 1. Per reference (a), request a change to <RANK> <NAME>’s LOD benefits from Drilling LOD (Reimbursement) to Non-Drilling LOD (Full Pay and Allowances) effective <date>. (Drilling LOD to Non-Drilling LOD) 2. Per enclosure (1), my treating physician has determined that I am unable (incapacitated) to perform my military duties due to my LOD injury/condition. 3. If I am also unable to work at my civilian employment, I may be entitled to receive Full Pay and Allowances (Incapacitation Pay). or (Non-Drilling LOD to Drilling LOD) 2. Per enclosure (1), my treating physician has determined that I may perform my military duties with some limitations (light duty). I still require continued medical treatment. 3. If I return to my civilian employment, I may be entitled to reimbursement for any lost civilian wages for time lost due to medical appointments related to my LOD injury/condition. 4. Name, E-Mail, telephone number, and fax number of the point of contact responsible for responding to inquiries for the extension request.

J. O. SAILOR

Encl (11)

LOD CLOSURE REQUEST FORMAT

1770 Date From: RANK/RATE Name, USN, SSN To: Commander, Navy Personnel Command (PERS-952) Via: Commanding Officer, Activity Subj: CLOSURE OF LINE OF DUTY (LOD) BENEFITS Ref: (a) SECNAVINST 1770.3D Encl: (1) Medical documentation (2) NAVPERS 1070/613 1. Per reference (a), request closure of my LOD case. I have been found fit for duty by my Primary Care Manager and do not require any additional treatment. Or 1. Per reference (a), I acknowledge that I still require medical care and have not been found fit for duty. However, I decline any further care via the LOD program and have signed the Page 13 refusing LOD benefits. 2. Name, E-Mail, telephone number, and fax number of the point of contact responsible for responding to inquiries for the closure request.

J. O. SAILOR

Encl (12)

JANUARY 2006 Encl (13)

LOD INCAPACITATION PAY REQUEST 1. TO (Benefit Issuing Authority) 2. DATE (MM/DD/YY)

Commander, Navy Personnel Command (PERS-952) SECTION I – PATIENT DATA

3. NAME (Last, First, Middle Initial) 4. RANK 5. SSN 6. DEPENDENTS?

YES NO

7. INJURY/ILLNESS/DISEASE

8. OCCUPATION AND JOB DESCRIPTION:

SECTION II – DISCLOSURE

I am requesting incapacitation pay benefits for the period of through . (MM/DD/YY) (MM/DD/YY)

I authorize the release of my civilian pay records for the purpose of requesting incapacitation pay benefits from the U.S. Navy. I understand that I must list all non-military income that I have received during the aforementioned period to include, but not limited to, wages, tips, commissions, worker’s compensation, income from income protection plan, vacation leave, sick leave, insurance proceeds, and disability compensation from the Department of Veteran’s Affairs. 9. SIGNATURE OF SAILOR/EMPLOYEE 10. DATE (MM/DD/YY) 11. INCOME RECEIVED DURING THIS PERIOD

a. NONMILITARY: $ b. VA: $

SECTION III– PHYSICIAN WORK CERTIFICATION 12. DATE OF LAST EXAM (MM/DD/YY): 13. OFFICE PHONE NUMBER:

14. BASED ON THE MEMBER’S OCCUPATION, CAN HE OR SHE PERFORM THEIR JOB? YES NO

15. SIGNATURE 16. NAME 17. DATE (MM/DD/YY)

SECTION IV – EMPLOYER

NOTE: When completing this form, refer to the dates that the member listed in section II to determine how much income the member earned or would have earned during that period. Used vacation and sick leave will count as earned income. If the member normally receives differential pay, use the average income and hours from three pay periods prior to the member’s medical condition.

18. COMPANY NAME 19. COMPANY ADDRESS 20. PHONE NUMBER

21. ANY INCOME EARNED DURING ABOVE PERIOD:

22. ANY INCOME LOST DURING ABOVE PERIOD:

23. HOURS NORMALLY WORKED PER WEEK:

24. HOURLY WAGE RATE OR ANNUAL SALARY:

$ $ $

25. Is this employee able to perform his/her job without the injury affecting the performance of those duties? YES NO

26. Does your company have a policy that prevents this employee from working with limitations if authorized by a physician? YES NO 27. SIGNATURE OF HR REPRESENTATIVE/EMPLOYER 28. PRINT NAME 29. DATE (MM/DD/YY)

SECTION V – COMMAND

30. COMMAND NAME 31. COMMAND ADDRESS 32. POINT OF CONTACT

33. PHONE NUMBER 34. FAX 35. EMAIL

36. INACTIVE DUTY PERFORMED? IF YES, DATE(S) PERFORMED: YES NO

37. MEDICAL BOARD COMPLETED? YES NO If yes, date:

38. SUBMITTED TO PEB? YES NO If yes, date:

I certify that I have verified the information provided in section IV with the employer or verified the member’s self-employment by tax return and/or W-2s.

39. CO SIGNATURE/ BY DIRECTION 40. PRINT NAME 41. DATE (MM/DD/YY)

This form must be completed with all required information. Failure to complete any portion of this form or attach required information will result in a delay of requested LOD incapacitation payment.

LOD Extension Request Format 1770 Date From: RANK/RATE Name, USN, SSN To: Commander, Navy Personnel Commander (PERS-952) Via: (1) Commanding Officer, Activity Ref: (a) SECNAVINST 1770.3D Subj: EXTENSION REQUEST FOR LINE OF DUTY (LOD) MEDICAL/DENTAL BENEFITS FOR

<RATE/RANK> <NAME>, USN, <SSN> 1. Per reference (a), the following information is submitted for the (first/second/third) extension request of medical/dental benefits. a. Date of injury and member's duty status at the time of Injury (i.e., Inactive Duty Training, Annual Training):. b. Brief (non-clinical) description of injury and cause:. c. Date member notified command of the injury:. d. Date Judge Advocate General Manual Line of Duty Investigation (JAGMAN LODI) completed (if required):. e. LOD effective date:. f. Date of member's last medical examination:. g. Chronological case history/appointments:. h. Enclose findings of Medical Board (MEB) or date it has been scheduled. Provide reason if MEB has not been scheduled:. i. Date case forwarded to Physical Evaluation Board (PEB):.

j. Civilian Employment Status:

1) I resumed the duties of my civilian employment position on:

2) Due to my LOD condition, I undertook a new position in the same civilian employment occupation on:

3) Due to my LOD condition, I undertook a new position in a new civilian employment occupation on:

2

Subj: EXTENSION REQUEST FOR INCAPACITATION PAY AND/OR MEDICAL BENEFITS FOR <RATE/RANK> <NAME>, USN, <SSN> k. Provide an explanation for delay in submitting the request for an extension:. 2. Name, E-Mail, telephone number, and fax number of the point of contact responsible for responding to inquiries for the extension request.

J. O. SAILOR

Encl (14)

LOD REINSTATEMENT REQUEST FORMAT 1770 Date From: RANK/RATE Name, USN, SSN To: Commander, Navy Personnel Command (PERS-952) Via: Commanding Officer, Activity Subj: REINSTATEMENT OF LINE OF DUTY (LOD) BENEFITS Ref: (a) SECNAVINST 1770.3D Encl: (1) Medical documentation 1. Per reference (a), request reinstatement of my LOD benefits. 2. Per enclosure (1), I was not returned to a duty status by my treating physician and was still undergoing treatment when my case was closed. I still require treatment and/or disposition through the Disability Evaluation System. or 2. Per enclosure (1), I provided my medical updates to my Medical Department Representative (MDR) every 30 days; however, my MDR failed to forward those documents to the LOD program manager. I still require treatment and/or disposition through the Disability Evaluation System. 3. Name, E-Mail, telephone number, and fax number of the point of contact responsible for responding to inquiries for the reinstatement request.

J. O. SAILOR

Encl (15)

For Enclosures 15 - 22: Please see the MMSO support document at http://www.tricare.mil/tma/mmso/downloads/ProcessGuideMMSO1.pdf for the most up to date processes. Dental has transitioned from MMSO to the new Active Duty Dental Program (ADDP) administered by United Concordia Companies, Inc. (United Concordia). Information on Dental LODs can be found at https://secure.addp-ucci.com/ddpddw/adsm/adsm.xhtml.

Encl (15-22)

MEDICAL RECORD CONSULTATION SHEET

REQUEST TO: FROM: (Requesting physician or activity) DATE OF REQUEST

REASON FOR REQUEST (Complaints and Findings)

PROVISIONAL DIAGNOSIS

DOCTOR’S SIGNATURE APPROVED PLACE OF CONSULTATION ROUTINE TODAY

BEDSIDE ON CALL 72 HOURS EMERGENCY

CONSULTATION REPORT RECORD REVIEWED Yes No PATIENT EXAMINED Yes No TELEMEDICINE Yes No

(Continue on reverse side) SIGNATURE AND TITLE DATE

HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT DEPARTMENT/SERVICE OF PATIENT DOD/USN

RELATIONSHIP TO SPONSOR SPONSOR’S NAME (Last, first, middle) SPONSOR’S ID NUMBER (SSN or Other) SELF

PATIENT’S IDENTIFICATION (For typed or written entries, give: Name – last, first, middle; ID no. (SSN or other); Sex; Date of Birth; Rank/Grade)

REGISTER NO. WARD NO.

CONSULTATION SHEET Medical Record

STANDARD FORM 513 (REV. 4-98) Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(b)(10)

Encl (23)

1850 Ser XX/

Date From: Commanding Officer, ______________ To: President, Physical Evaluation Board Ref: (1) SECNAVINST 1850.4E Subj: NON-MEDICAL ASSESSMENT (NMA) IN THE CASE OF RANK/RATE NAME, USN, SSN/DESIG 1. Purpose: The NMA describes how well the member performs his/her military duties, e.g., rating duties or exercises, participation in the PFA, etc. The first half of this document, “Questionnaire”, details basic data on the service member. The purpose of the second half, Commanding Officer’s Comments”, is for the CO to comment on what the member can and cannot do. Be as specific as possible about what duties and responsibilities the member can and cannot perform. Explain how the member’s medical condition has affected the member’s ability to perform the duties of his/her rate or MOS, and the reality of the service member’s contribution to the unit. The CO’s insights are crucial in assisting the PEB in making a determination of Fit or Unfit. Prior to writing the NMA, the CO should first review the member’s Medical Board (MEB) or medical record to gain a better understanding of the member’s medical condition.

2. Questionnaire. The following assessment is submitted to assist the PEB in their determination of Fitness/Unfitness of SNM:

a. Service member’s rating/NEC/Primary Specialty: _________ (Examples: AO3 Aviation Ordnanceman; 1100/Surface Warfare Officer, etc.).

b. Member’s current position: ______________. c. Is the member currently working out of his/her specialty because of

his/her medical condition? (Yes/no) d. Date member last passed the PFA:_________(MM/YY) e. Can member presently take the PRT/PFT? (yes/no/partial) f. Member’s height and weight: ________ (inches/lbs). g. Is the member within weight and body fat standards? (yes/no) If not,

is the member on weight control? (yes/no/N/A) h. To your knowledge, is the member fully complying with the prescribed

appointments and treatment for the therapy? (yes/no). Has the member complied in the past? (yes/no)

i. What is the average number of work hours per week that the member’s

condition has required the member to be away from current duties for treatment, evaluation, and/or recuperation? __________

j. Is member pending disciplinary action or involuntary administrative

separation for misconduct? (yes/no) If so, for what?

Encl (24)

2

Subj: NON-MEDICAL ASSESSMENT (NMA) IN THE CASE OF RANK/RATE NAME, USN, SSN/DESIG

k. What is the member’s current length of service and date of entry

into service? l. LOS: _______(years/months) ADSD/ADBD:_____(mo/yr) m. Considering the member’s current physical condition, is he/she

worldwide assignable? (yes/no) n. Does the member have good potential for continued service in his/her

present physical and mental condition? (yes/no) o. Does the member desire to continue his/her military service?

(Yes/no) 3. Commanding Officer’s Comments: (use additional pages as necessary) 4. POC at this command is _________ (name/rank/position) at (Comm)________/(DSN) _________ or (email) ___________

C. O. SIGNATURE (per Para 11001)

Revised Nov 2008

SUBMISSION FOR SEVERANCE PAY PROCESS 1. To separate enlisted members due to PEB Unfit finding: Complete DD256N Complete NAVPERS 1070/613 (refer to message for reason for separation) 2. Request Statement of Service from PERS-912 3. Make a statement in cover letter stating whether the member was in the service on 24 Sep 1975. 4. Official request on command letterhead should be forwarded to DFAS at commercial (216) 204-4385 or fax (216) 522-6661 and include the following: NAVPERS 1070/613 DD256N Statement of Service Copy of message Statement whether member was in the service on 24 Sep 75 5. Discharge the member from NSIPS. 6. Upon completion, forward a copy of this information to LOD shop (PERS-952) at email: lod@navy.mil to be included in the member’s closed case file. 7. Advise member that DFAS takes approximately 90 days to process severance pay. In the event they do not receive a check/direct deposit they will need to contact DFAS. **NOTE** For Officers: Only NPC (PERS-91) can discharge Navy Reserve Officers. PERS-91 will submit all required documents to DFAS. A copy of the discharge letter will be sent to the NOSC by PERS-95.

Encl (25) 6100

2

Date From: Rank/Rate Name, USN, SSN/Desig To: President, Physical Evaluation Board Via: (1) Commanding Officer, Activity (2) Commander, RCC _________ (3) Commander, Navy Personnel Command (PERS-952) Subj: REQUEST FOR PHYSICAL EVALUATION BOARD (PEB) TO DETERMINE RETENTION IN THE NAVY RESERVE FOR RANK/RATE NAME, USN, SSN/DESIG Ref: (a) BUPERSINST 1001.39F (b) SECNAVINST 1850.4E Encl: (1) Report of Medical Examination (DD-2808), Report of Medical History (DD-2807-1) of DATE ** this must be within 6 months (2) Current Evaluation/Consultation report from Civilian Physician/Military Physician on subject member (3) Original Retention Package (4) Non-Medical Assessment Questionnaire and Summary (5) LOD Understanding ltr of DATE (6) Member’s Election of options ltr (7) BUMED recommendation ltr Ser ## of DATE (8) COMNAVPERSCOM msg of DATE 1. Per references (a) and (b), enclosures (1) and (8), are forwarded for retention consideration in the Navy Reserve.

I. M. SAILOR FIRST ENDORSEMENT on Rank/Rate Name, USN, SSN/Design ltr of DATE From: Commanding Officer, Activity To: President, Physical Evaluation Board Via: (1) Commander, Your REDCOM (2) Commander, Navy Personnel Command (PERS-952) Subj: REQUEST FOR PHYSICAL EVALUATION BOARD (PEB) TO DETERMINE RETENTION IN THE NAVY RESERVE FOR RANK/RATE NAME, USN, SSN/DESIG 1. Forwarded.

C. O. SIGNATURE

Encl (26)

Date: ________ From: Rank/Rate Firstname MI. Lastname, USN, SSN/Desig To: Deputy Chief of Naval Operations (Manpower, Personnel, Training, & Education) (N1) Subj: LINE OF DUTY (LOD) UNDERSTANDING Ref: (a) SECNAVINST 1770.3D 1. Per reference (a), to be eligible for LOD benefits, the illness, injury, or disease must have been aggravated or incurred while in the performance of Navy Reserve duties or while in direct travel to or from such duty. a. ____ I understand that my injury, illness, or disease was NOT incurred

or aggravated during my Navy Reserve service. If my injury, illness, or disease was incurred or aggravated while I was on active duty and I was discharged without a determination of “fitness for duty”, I must submit a request to the Board of Corrections of Naval Records (BCNR). I may refer to MILPERSMAN Article 1000-150 for BCNR guidance.

b. ____ I believe that my injury, illness, or disease was related to Navy

Reserve service. I wish to apply for LOD benefits for the following injury(ies), illness(es), and/or disease(s): . I will use this retention package along with the following information as my request for benefits:

(1) ____ Medical documentation at the time of incident. (2) ____ Copies of orders/DD214 showing duty status at time of

incident. (3) ____ Completed DD Form 261, Report of Investigation Line of

Duty and Misconduct Status.

I. M. SAILOR

Encl (27)

APPENDIX A

CHECKLIST FOR A LINE OF DUTY (LOD) REQUEST

The following items are required for all LOD requests. _____ 1. Command letter requesting a Line of Duty _____ 2. Copy of LOD Privacy Act _____ 3. Copy of Orders & DD214 / Drill muster sheet at the time

of incident _____ 4. Copy of all available medical documentation from the

time of incident (civilian, military, ER reports) _____ 5. Copy of Motor Vehicle Accident Report (if available) _____ 6. Copy of chronological medical care pertaining to

injury, illness or diagnosis (if applicable) _____ 7. Copy of previous physical exams / Periodic Health

Assessment (PHA) / Dental (T-2) exam / Pre-Mob & Post Mob assessment (as applicable)

_____ 8. Statement from witnesses (if applicable) _____ 9. Line of Duty Investigation (DD Form 261) _____ 10. Copy of Physical Fitness Assessment (PFA) screening /

PFA & BCA result (if applicable) _____ 11. Authorization for Disclosure of Medical or Dental

Information (DD form 2870) ______12. Page 2 ______13. LOD and Incapacitation Pay Page 13’s.

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APPENDIX B

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APPENDIX C

CHECKLIST FOR A INCAPACITATION PAY REQUEST The following items are required for all incapacitation pay requests: 1. LOD Incapacitation Pay Request 2. Physician Recommendation/Limitations for Civilian

Employment form or medical treatment notes 3. Page 13 Member’s Privileges and Responsibilities for LOD

(Initial Request) 4. Page 13 Report of Civilian Income (Initial Request) 5. Current Page 2 to Verify Dependent Status (Initial Request) 6. Projected 6-month treatment plan (Initial Request)

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APPENDIX D

CHECKLIST FOR PHYSICAL EVALUATION BOARD (PEB) PACKAGES The following items are required for all PEB packages. _____ 1. Member request letter _____ 2. Physical Examination (within 6 months) _____ 3. Copy of original retention package _____ 4. Non-Medical Assessment (within 6 months) _____ 5. BUMED risk classification recommendation letter _____ 6. PERS-95 risk classification message/letter _____ 7. LOD Understanding letter _____ 8. Member’s election of PEB review

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APPENDIX E

Additional Points of Contact 1. Defense Finance and Accounting Service Cleveland: Commercial: (216) 522-5335 / 1238 2. Bureau of Medicine and Surgery (M32): Address: 2300 E Street NW, Washington, DC 20372 DSN: 762-xxxx Commercial: (202)762-3484 / 3466 3. COMNAVRESFOR (N01M), Force Medical: DSN: 678-xxxx Commercial: (504) 678-6309 / 1085 Fax: (504) 678-5485 4. TRICARE: Toll Free: 1-888-DOD-CARE Website: www.tricare.osd.mil/reserve 5. COMNAVPERSCOM (PERS-95): DSN: 882-xxxx Commercial: (901) 874-4229

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Revised: 08/23/2012

APPENDIX F

Military Medical Support Office (MMSO) Phone: 888-647-6676, Option 7 then the extension shown next to name below

Service Point of Contact (SPOC) – Patient Administration Section

Senior SPOC* North South West

Arm

y

Mr. Ed Jones; X6604 edward.jones2@med.navy.mil

Joshua Cogar; X6680 joshua.cogar@med.navy.mil Joshua Cogar; X6680 MSG Mary Cannon-Lee; x6739

mary.cannonlee@med.navy.mil

Air

Forc

e LtCol James Whitton; X 6729

James.Whitton@med.navy.mil

MSgt Jodi Yenerall; X6715

jodi.yenerall@med.navy.mil

MSgt Chris Boyle; X6713 or

MSgt Jodi Yenerall; X6715

MSgt Chris Boyle; X6713 christopher.boyle@med.navy.mil

Nav

y &

M

arin

es

LCDR Jori Brajer; X6686

Jori.brajer@med.navy.mil HM1 Kim Parker; X6672

kim.parker@med.navy.mil

Navy: HM1 Kim Parker; X6672

Marines: Mr. Greg Kaszubowski;

X6709

Mr. Greg Kaszubowski; X6709 greg.kaszubowski@ med.navy.mil

USC

G

LCDR Don Boyer; X6716

Donald.Boyer@ med.navy.mil LCDR Don Boyer; X6716 LCDR Don Boyer; X6716 LCDR Don Boyer; X6716

*All questions may be directed to a Senior SPOC regardless of region

Medical Contacts

Dental Contacts LOD Authorizations: x3367 Medical Claims Questions: x3352 Pre-authorization fax line: (847) 688-7394 Eligibility fax line: (847) 688-6138 or 6460

Claims and Authorization Questions x3365

MMSO Mailing/Shipping Addresses Mailing Address: Military Medical Support Office P.O. Box 886999 Great Lakes, IL 60088-6999 FOR UPS/FED-EX ONLY 2750 Sheridan Road, Bldg. 38H Great Lakes, IL 60088-6999

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